HCMC physician: ‘We’re not in a crisis quite yet, but we’re teetering right at that brink’

Dr. Matthew Prekker

The Southwest Journal is documenting the coronavirus pandemic by recording the personal stories of Minneapolis residents and workers whose daily lives are in a state of flux. As the outbreak evolves, we will be checking in with the participants regularly. Read all of the stories here.

This interview was conducted over the phone and has been edited for length and clarity.

Matthew Prekker, critical care physician, Hennepin County Medical Center

My wife, Frances, and I live on Upton Avenue in Linden Hills with our four children. She’s a pediatrician at Hennepin. We chose the area because of the lakes — we love running and biking — and because the schools are fantastic. We have kids in the Lake Harriet community schools and send two of our children over to Windom for Spanish immersion.

I grew up in Northeast Minneapolis, and I did medical school and got a public health master’s at the University of Minnesota. Later, I sub-specialized in pulmonary and critical care medicine with a fellowship at the University of Washington. In 2014, I was able to come back to HCMC as faculty. I work half my time in the emergency department and half in the pulmonary care unit. So I have a background well-suited for the pandemic.

Working in medicine in the Midwest, we always follow the trends and outbreaks from the coast; we seem to see things a little later. Starting in March and especially in April, we had cases here in Minnesota. We did a lot of planning to prepare for a surge in patients; we’re a safety net hospital and we tried to tailor our planning to serve folks who don’t have a lot of resources.

Fortunately, we have a lot of ICU beds here, but we knew it wouldn’t be enough. I worked with colleagues to develop more ICU beds in unconventional spaces in the hospital. Over the last two weeks we’ve had to use those beds as we’ve been particularly hard hit by critically ill COVID patients. We’ve filled our ICU beds on the seventh floor and expanded down to the burn ICU on the fourth floor and have since expanded into a lightly used same-day surgery center down in the first floor that we’ve been able to repurpose.

The west metro seems to be experiencing a lot higher ICU volumes than the east metro so far. The folks we’re seeing who are critically ill are predominately folks from minority communities. The Latino and Somali communities, from our perspective, have been very heavily affected by this.

It’s a really trying time for everyone because not only are we stretching our resources and being as resilient as we can to take care of these very sick patients, their families aren’t able to visit them in the hospital. It just adds that much more stress on these very concerned families having to rely more on our interpreters.

My clinical hours have gone up; I’m working more and longer hours. This is a hospital with a wonderful culture, so the camaraderie hasn’t changed. But the work is hard. I don’t think I’ve ever intubated as many people as I did last week. It’s intense seeing the continued surge of patients still coming to our medical center but also dealing with those later critical care issues with patients intubated a month ago.

There’s a lot written about how this disease is unlike things we’ve seen before. But we’ve actually seen a lot of features similar to what we’ve done in the past for other respiratory diseases, and we haven’t had to deviate too much from what we’ve done in the past. The areas that are different are the patients’ blood-oxygen levels in general are lower than other diseases we’ve seen, and we’ve had to adjust our frame of reference to tolerate things that would have made us nervous in the past.

What’s most different is the personal protective equipment [PPE], the shields and masks we wear. Trying to do a critical procedure — where we sedate and paralyze someone’s muscles and then place a breathing tube into their lungs — it’s hard to communicate when you can’t see other people’s mouths and you can’t hear very well. So we’ve had to be creative as a team in terms of how we carry out that type of procedure.

The volume of patients is higher and there’s an added intellectual burden in thinking through all these complex cases, but the mechanics of the procedures haven’t really changed. At the end of the day, we’re exhausted, just emotionally and physically tired, which doesn’t happen every day in our regular practice.

As we’ve looked at our first 80 or so critically ill COVID patients on ventilators, we’ve seen a survival rate around 70%. These numbers are rough estimates, but we’re doing pretty well compared with what we’ve seen come out of colleagues in New Jersey and New York and Louisiana and other places. It doesn’t seem to be as doom or gloom as other places have reported. But it’s not all folks who are elderly struggling with this disease; we have a number of 30-, 40- and 50-year-olds in our ICU who are really battling for their life now. That adds more than a little extra stress.

With our planning, we haven’t been overwhelmed [in terms of ventilator supply], but we’re watching very closely to see if all these social distancing and community interventions will flatten our surge. We have a great supply of PPE at the hospital; we have not been short at all. We’ve been thoughtful about conserving, so I use an N95 mask for multiple days, which allows us to extend our supply. A lot of the procedures we do in critical care force us to get right up to the patient’s face, so we’re always careful about putting on that PPE. We haven’t seen a large burden of health care worker infections at our hospital.

Testing is like night and day compared with early April. I don’t feel like we’re totally where we should be as a state yet, but clinically at the hospital, I can test anyone I think needs it at any time. We’re lucky in that regard.

In our electronic health record we have a way you can look through units of the hospital and see at a glance who’s positive for coronavirus, and it’s just been a sea of red — it’s gone from green to red almost exclusively over the past few weeks. The volume of folks we’re seeing come in without COVID has gone down. We haven’t seen the typical volume of heart attacks or strokes; I don’t know where they’re getting care or what’s happening. We separate COVID negative patients from infected patients, and I’m not aware of a case where someone has contracted COVID in the hospital.

[The reopening of the state] makes me very nervous, but it’s a hard thing. I feel a bit divided about it in that my work at the hospital is very intense — my wife and I both struggle a bit to leave that work at the hospital and be there for our kids — but when we get home, we feel the same stress as other families, doing distance learning, trying to get our kids what they need. So I’m nervous about it, but I know it’s got to happen. I hope people stick together and we do it intelligently.

We have the busiest ED in the state, and we get some unusual and sometimes bizarre injuries. Anything that happens we can take care of at the hospital, so I think that resiliency has served us well in the pandemic. There have been a lot of changing guidelines and recommendations for taking care of ourselves and our patients, and I think our staff have done a great job of adapting to that. There is that undercurrent of unease: Folks are worried and thinking about their families and loved ones during their day-to-day work.

But we can get through this, we will get through this, and we want to do it so our most vulnerable patients get the care they need. We take care of a lot of folks who are homeless and houseless at the moment. We partner with different shelters in town, finding safe and clean places for everyone to live and get care.

In my normal practice, I spend about 20% of my time on research. Now I spend a lot of my nights and weekends getting the research work done, just out of necessity. I think it’s important work and fortunately my family can support me.

A lot of my role is partnering with other hospitals around the country that do a lot of research in networks [such as the IVY Network, a 16-site consortium of academic medication centers funded by the Centers for Disease Control]. So when the pandemic came, the networks were able to get funding and really pivot almost immediately to studying this new disease.

The study I’m especially proud of is this health care worker serology study we’re in the middle of now. This was a great morale boost at the hospital when health care workers didn’t initially know if they were making antibodies, if they’d been exposed to this virus or what their immune system was doing. This study, which started at the end of April, allowed us to recruit 250 of my colleagues — predominantly ICU nurses but also health aides, respiratory therapists and other physicians. There was a lot of enthusiasm. We started these screening blitzes at 6:30 in the morning and we had a line starting at 6 a.m.

They volunteered to fill out a survey, get a nose swab and blood drawn. That tube of blood is now at the CDC and they’re testing those folks for antibodies against the coronavirus. We’ll get to share the results on an individual basis with the health care workers. They’ll have a bit more sense of control about their status, which helps you get through a day of work.

We’ll understand who had antibodies at the end of April, and we’re going to repeat that same process 60 days later, at the end of June, and know in that interval of time who’s converted — who has gone from antibody negative to positive. We’ll combine our data with data from 16 other centers nationwide to have a great look at what’s going on with health care workers’ immune systems. Although there’s a caveat: Nobody really knows the meaning of those antibodies quite yet. How protective are they against reinfection? Should they inform what you do in the community or at work? Those are questions we still need to figure out.

I’ve also been studying losartan and remdesivir, though that’s more of a team effort. There’s so much uncertainty now in terms of treatment. In my experience, I’ve never seen something like this — where we see so much of a disease in a pandemic form that we don’t know enough about. The best thing is to do these trials and do these important experiments to know what will benefit our patients in the future.

Yet we don’t really have much that we know is effective besides supportive care. The stuff I’m trained to do — to support people on ventilators and resuscitate and stabilize them in the ED — is what’s paying the biggest dividends. Other therapies are truly experimental. I can’t say any one of the drug treatments has been eye opening in reversing the course of this. We’re lucky to be able to use them, but we need more time to see how much they’re benefitting people.

Some treatments have probably been prematurely elevated to standard of care. The way some people embraced hydroxychloroquine, for example. As our federal government and certain heads of the government have really embraced that drug, I think that got way ahead of the science with that medication. That’s fallen off of our treatment algorithm here at the hospital, and we’re not using it anymore. That might have been a flash in the pan, which is disappointing, because it does have risks.

The summary data about number of deaths per day or new diagnoses per day — those graphs are downtrending. But the things I see at the hospital and deal with day to day is not a downtrend. That’s back to the question of: Do we open up our communities? Do we try to get our families and kids back to a semblance of a normal life?

If that drives more respiratory, critical illness, we’re going to be overwhelmed at the hospital. Things are getting very, very busy. We’re activating our crisis and surge plans. We’re not in a crisis quite yet, but we’re teetering right at that brink. I don’t think that’s gotten as much coverage as, “Hey look, everybody’s saying it’s time to reopen.”

My wife and I haven’t really isolated ourselves at home. We’re both around folks with COVID at the hospital, and that’s just a part of life. We do a lot of handwashing. We make our kids wear masks when they go out in public. We’ve really kept them, unfortunately, from their friends and tried not to do family gatherings. But inside the house, we haven’t done much differently, and we’ve been very lucky that neither of us have been sick and our kids have been healthy.

What’s happening at the hospital is always on my wife’s and my mind. The emails and communications from work are around the clock now to keep everyone on the same page about our surge plan and treatment guidelines. It’s been hard to stay positive. It’s easy to get nihilistic and negative about how many sick patients we have at the hospital now. But we look to each other, to friends in the community, to family, to more experienced colleagues to get through this.

I get together with a small group of other dads from Fulton and Linden Hills and go running on Saturday mornings around the lakes. We run 6 feet apart, separate trails, but it’s still good to see those guys from a distance. That kind of stuff gives me a little shot of energy to get into a new week.

I like to bike to work, so my wife and I both bike along the lakes and then up the trails to Hennepin. That’s a time when I try to reorient myself and say, “I’m going home now. I’m going to put a smile on my face. The workday is done. It’s time to be a dad now.” I’ve had to pay a bit more mindfulness to that lately than I have in the past.

Our kids know something’s going on. The oldest is 12, and then we have a 9-, a 6- and a 3-year-old. They ask all the time, “Hey, what’s going on at the hospital? Was your day OK? What happened today?” And for younger kids, I think that’s pretty perceptive.


VOICES FROM THE PANDEMIC

 You can read all of the stories here.