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Pediatricians show their mettle as coronavirus sweeps the nation

April 21, 2020
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Editor's note: For the latest news on coronavirus disease 2019, visit https://www.aappublications.org/news/2020/01/28/coronavirus.

Pediatricians are not immune to the havoc wreaked by the coronavirus disease 2019 (COVID-19) pandemic. Despite the uncertainty and seemingly endless challenges, they have kept their patients and colleagues front and center. Here are some of their stories.

From Washington state to Washington, D.C.

When COVID-19 hit, U.S. Rep. Kim Schrier, M.D., FAAP (D-Wash.), found herself straddling both sides of the country.

All eyes were on her home state of Washington, which faced one of the first outbreaks, as well as Washington, D.C., where she was among lawmakers who were hammering out legislation to address the virus.

As the first pediatrician elected to Congress and the only female physician in Congress, Dr. Schrier served as a trusted source of health information not only for her constituents, but also her colleagues in the U.S. Capitol.

For her, the threat of the pandemic was very real and urgent given what was happening in Washington state.

Early on, this personal obligation hit a crescendo during a caucus breakfast meeting while she watched her colleagues eat from a buffet and cough into their hands. Dr. Schrier stood up among about 200 of her fellow legislators and voiced her concerns.

“You may think this is not coming to your state, but it's probably already there and you need to take this very seriously,” she said she told the group. At the time, a nursing home in Washington state was making news as it experienced one of the first outbreaks in the country.

She reminded lawmakers that even mundane tasks needed to be taken with great care, like sneezing or coughing into an elbow, avoiding elevator buttons and washing hands constantly.

Dr. Schrier admitted it was out of character for her to give an impassioned speech during a caucus meeting, but many of her colleagues were grateful for her advice.

“(It was) really kind of a wake up,” she said.

She also recalled how her friends reached out to set up playdates for their children after the schools were shut down, and similarly, she had to explain why that was not a good idea.

Over several weeks, Congress passed three bills to combat the coronavirus. Dr. Schrier was in Washington, D.C., for the first two, and back in Washington state for passage of the third, which came together with many emails and phone calls, she said.

“It did happen with remarkable speed and with cooperation between both parties,” Dr. Schrier said.

Two of Dr. Schrier's priorities were access to COVID-19 testing and policies to support children's well-being, like the expansion of Supplemental Nutrition Assistance Program benefits and ensuring children would not go hungry if schools closed.

“Our health care system is going to need a lot more,” she said. Among her concerns are financial support for clinics and equal pay for telehealth.

When AAP News spoke with Dr. Schrier, she was back home working in her district. Her days were packed with calls, as she and her staff listened to constituents and focused on policies to address the virus.

“Everybody has their own circumstance, and so we're really just trying to be a resource for people,” she said.

When asked whether she misses being a practicing pediatrician as she serves in Congress, Dr. Schrier said she always has both ideas in her mind, but she feels she is “doing a greater good on the national scale right now.” Instead of giving advice patient-by-patient, she has a platform to reach her entire state and the country.

On the front line: ‘It’s very intense’

Pediatricians like to say children are not little adults. That implies adults are not big children.

Katherine M. O'Connor, M.D., FAAP, learned that firsthand as New York City became the epicenter of the COVID-19 outbreak in late March.

As the city experienced a crush of patients, The Children’s Hospital at Montefiore in the Bronx was among pediatric hospitals that opened their doors to adult patients.

“It’s a privilege to be able to provide some help during this crisis for our city and our world, but to not have practiced adult medicine in 17 years and have it happen so quickly is quite overwhelming,” said Dr. O’Connor, attending physician and associate division director for pediatric hospital medicine.

Over the course of three weeks, Dr. O’Connor and her colleagues went from talking about the virus and watching trends to testing and treating pediatric patients to caring for adults with COVID-19.

“This miraculous virus that seems to be kind to children has led to now pediatricians changing course in career quickly,” she said.

And that change has been daunting.

“The (adult) patients, when they all came to the hospital, I didn’t expect that they would all be so hungry for oxygen, just needing so much more oxygen than we’re used to giving,” Dr. O’Connor said. “It’s not just like they’re kind of feeling a little bit unwell sitting in the hospital. They’re really needing help.”

In addition, her relationship with patients is unlike anything she has experienced.

“We’re trying to be mindful of how many times people come in contact with patients and using up the protective equipment to make sure we continue to have access to it,” Dr. O’Connor said. “And so, we’re having to have conversations with patients from doorways that we would typically have holding patients’ hands.”

In the midst of the uncertainty and unfamiliarity, Dr. O’Connor was bracing for what was to come.

“As pediatricians, we don’t have to face death as often as our adult colleagues do. And I think that we are very afraid to take care of dying patients,” she said. “They are often without family members, and this is all very new this week, so just having to jump into that will be something that’s scaring me personally.”

Dr. O’Connor acknowledged that she also was concerned about her own health, but said, “It’s certainly not something that’s going to stop me from being able to help other people who are suffering.”

So like a soldier on the battlefield, Dr. O’Connor marched on.

“It’s nothing I could have ever imagined in my career as a pediatrician,” Dr. O’Connor said. “It might sound overdramatic at times, but it’s definitely the closest thing that I’ve felt to being in a battle or on the front line of something. It’s very intense.”

‘Am I doing enough?’

As she sits in her Connecticut home checking in with patients and families via telemedicine, Carol Cohen Weitzman, M.D., FAAP, says what she is doing does not compare with the experiences of her colleagues who are treating patients with COVID-19.

“I’m not a front line guy,” said Dr. Weitzman, director of the CT Center for Developmental Pediatrics. “I’m so spared from some of the really intense things that some people are experiencing. I just don’t put myself in the same category.”

Her patients and families, however, might disagree.

Dr. Weitzman treats kids with autism, attention-deficit/hyperactivity disorder, behavior issues, anxiety and cognitive limitations.

Since she shifted to telehealth, she has been working primarily with parents. She provides them with strategies and advice to get through what she calls “weird and unusual times.”

She encourages families who have a child with autism to keep their days as structured and predictable as possible. She suggests they write out a daily schedule and keep regular wakeup and bed times. She passes along resources such as social stories on handwashing and why people are wearing masks.

For patients with anxiety, she talks with parents about the importance of acknowledging children’s worries and helping them use calming strategies, particularly mindfulness.

She encourages all families to talk with their kids about what is going on in world, tailoring it to their developmental and cognitive level, and allowing kids to share what’s on their minds.

Dr. Weitzman also is urging parents to take care of themselves.

“There is a huge, huge amount of parental anxiety,” said Dr. Weitzman, professor emeritus of pediatrics and Child Study Center, and senior research scientist at Yale School of Medicine. Parents are worried about being able to educate their kids, about their jobs and finances, about themselves or their children getting sick.

“One message I’m giving and hear many of my colleagues giving to parents is: ‘Be kind to yourselves.’”

Still, Dr. Weitzman wonders whether she is doing enough for her families.

“I struggle with trying to figure out how to reach all of the families and what messaging they want from me and how to be there for them in ways that are helpful and meaningful,” she said. “…That is something that challenges me a little bit. Am I doing enough for these families? Can I do more? How should I do it?”

Adapting on the fly

You could say the stars aligned for Ruben J. Rucoba, M.D., FAAP.

After having a bone marrow transplant 16 years ago, he slowly was gravitating away from seeing patients. Last year, he took a newly created position as director of medical services for PediaTrust, a “super group” made up of 11 pediatric primary care practices and one specialty pediatric practice in the Chicago area. Among his duties was to start a telemedicine program.

He launched the program in December, but it was difficult to get parents on board due to lack of insurance coverage.

Then coronavirus hit.

“For me, telemedicine was going to be the thing of the future anyway, and now it’s just taken off,” he said.

The super group, which includes 70 doctors, made a slew of other changes to make sure they could continue caring for their 70,000 patients during the pandemic.

The overriding concern was to keep kids who might have coronavirus out of the offices so they didn’t expose other patients and staff, and to preserve personal protective equipment (PPE). So patients with severe symptoms were sent to an emergency department.

“We want to do what’s right for patients. We want to do what’s right for our staff, and we want to do what’s right for the general health care system overall,” Dr. Rucoba said.

If children were thought to have strep throat or the flu, offices tried to limit the number of people who came in contact with them in case they had coronavirus. The patient would be put into an exam room immediately, and a nurse would call the parent on a cellphone to get the history. Then, a pediatrician would go in briefly to get vitals and do an exam.

Some offices set up areas in the parking lot, where one staff member donned in PPE would do tests for strep, flu or respiratory syncytial virus.

“Patients actually like that,” Dr. Rucoba said. “They don’t want to come into the office. They don’t mind these setups.”

As the pandemic rages, PediaTrust is thinking about how to catch up with well-child visits that are being put off. One idea is to use telemedicine to conduct most of the visit and then set up something like a flu clinic to get vitals and administer vaccines.

While PediaTrust has adapted quickly, Dr. Rucoba acknowledged the group didn’t have a disaster plan.

“We were flying by the seat of our pants,” he said.

‘We were already jogging. We just had to start running.’

The pivot to virtual communications for patient care and staff communications was a challenge for many practices.

For Tamalpais Pediatrics in Larkspur and Navato, Calif., operational challenges generally were manageable, thanks to early telehealth adoption that fell into place at the right time.

The practices had been utilizing telehealth for behavioral care for more than a year and ramping up use for acute care in recent months. So, when patient visits to the office decreased, the familiarity with the technology and an established workflow helped expedite integration of telehealth on a greater scale.

“We were already jogging. We just had to start running,” said Nelson Branco, M.D., FAAP, a member of the practice staff and AAP California Chapter 1 vice president.

Like so many practices with diminishing well visits, these pediatricians are finding gaps in their schedules. Scanning their patient rosters, they identify children with chronic illnesses, such as asthma or anxiety, and contact parents to offer televisit check-ins.

“It is satisfying to me to have a little bit of time to talk with the patient about their condition and how they are handling shelter in place. Parents appreciate it also,” Dr. Branco said.

With the near daily updates about COVID-19 and its impact on practice, communication among staff is critical. A relatively new phone system that works as a virtual network makes it possible for most of the practices’ staff to work from home. Each morning, the practices have a telehuddle where they discuss “Where we are today. What is our plan? What we’re changing.”

It’s been helpful to discuss cases as a team, Dr. Branco explained. “If we have a case that we think merits testing, we can discuss it. Not so we can talk each other out of doing what is clinically indicated. It’s so we all get a sense of what is each other’s threshold for testing and their criteria for testing, so that we have consistency in the group.”

During these challenging times, “What rings true for me,” Dr. Branco said, “is the importance of communication and flexibility.”

Sew good: Crafters know no borders

What started as a pediatrician’s project to extend a mask supply by a couple of weeks has turned into a labor of love for a growing group of crafters 2,900 miles away.

Like health care professionals worldwide, Tracy MacPherson (Dr. Mac), M.D., FAAP, recognized in the early days of the pandemic that she would not have enough masks for her staff of 24 in Orangeburg, S.C. She ordered, but nothing arrived.

She attempted to stretch the practice’s meager supply by having staff wear masks for several days. The plan was not sustainable. “This is just not right,” she said. “I’ve got enough masks for about two weeks, and I’ve got to get ahead of this thing.”

She set out to make her own masks. In the absence (at the time) of any official guidance on what’s effective, she watched several YouTube videos on how to make her own. Triple ply, with the top and bottom layers made of tightly woven fabric and a layer of interfacing in between. Rummaging through a plastic tub of sewing remnants, she found some colorful fabric with a lizard and snake pattern. “The kids will like that,” she thought.

That night, she sewed one, then posted a picture and instructions on Facebook. “It was really quite easy, so I decided to make at least one for every one of my providers.”

Out of supplies, she sent her husband to the store with a list. He came home empty-handed. According to the clerk, someone had posted mask-making instructions on social media, and supplies flew off the shelves within hours. The local community had taken up the cause and began to sew masks, too. Soon, masks began to show up on her doorstep.

Meanwhile, in Kamloops, B.C., Canada, Dr. Mac’s sister saw the Facebook post. Her husband, an emergency department physician, had just used his last mask. Sizing up the homemade mask, he said, “It’s better than nothing. Make me one.”

From there, a community effort to make masks flourished. A well-coordinated Facebook group called Sew the Curve Kamloops boasts more than 1,000 members.

Eventually, the hospital received its supply of surgical masks. Still, there continues to be great need for Sew the Curve Kamloops masks, and they are being put to good use. New mothers, for example, are going home with the masks for themselves and their family members.

As for Dr. Mac, she put her mask-making days behind her, once a colleague received a delivery of N95 masks. But in Orangeburg and Kamloops, people continue to work with each other for a common cause.

“It is really joyful to see a community come together like this,” she said.

A practice within a practice

Stapleton Pediatrics in Denver has more than a waiting room for ill patients: It has a waiting office.

Last August, the six-pediatrician practice co-founded by Noah J. Makovsky, M.D., FAAP, and Brandon S. Davison-Tracy, M.D., FAAP, opened a second location, Pearl Street Pediatrics, about 20 minutes away. To prepare for possible COVID-19 patients, Pearl Street was used for well patient care, while the main office became the designated location for sick patients. A separate section is used for those who might have COVID-19.

“We put up different temporary walls in our practice so when people come in and out of our COVID section, they are completely separate … like a practice within a practice,” Dr. Makovsky (“Dr. Noah”) said. The arrangement helps protect staff and families.

The office also signed up for telehealth.

“The ones who have taken advantage have been ecstatic because they are in the comfort of their own homes,” Dr. Makovsky said. “They don’t have to feel nervous about coming in; they have the ability to see their provider and really get a chance to talk.”

In another first, Dr. Makovsky and Dr. Davison-Tracy created a Facebook video message that introduced office changes and how virtual visits work, with plans to continue weekly.

The office has seen an uptick in behavioral consults, primarily due to anxiety, in both young children and teens. Staff members also are anxious (when Dr. Makovsky spoke to AAP News,the office had no testing equipment and limited personal protective gear), but regular meetings help reassure employees. “They feel like they are in an environment where we are taking all the potential steps to keep the staff safe and other patients and families safe,” Dr. Makovsky said.

A big worry now is keeping the business afloat. There are 45 employees, including physician assistants and nurse practitioners. While the practice has seen some patients with flu and respiratory syncytial virus, those illnesses are decreasing rapidly or patients are not coming in to be diagnosed, he said.

The concern is shared by others in the area. Practice volumes in Denver and beyond are down by 40%-50%, Dr. Makovsky said.

“The foundation of primary care in the country in itself could be threatened by this crisis if we can’t make it to the other side,” Dr. Makovsky said. “That’s very much on our minds.”

Immigrant families: ‘Do they know we’re still here?’

For Kimberly A. Mukerjee, M.D., M.P.H., FAAP, and colleagues in New Orleans, the state’s stay-at-home order to help stop the spread of the virus has had a downside: They can’t monitor the health and well-being of many of their immigrant patients.

Dr. Mukerjee, who speaks Spanish, said most of the patients she sees at various clinics lack insurance. The pandemic has caused many of them to go off the radar.

“For me, it’s been a bit of a struggle knowing how to reach families and trying to address the full breath of their needs. I worry so much about the economic impact on families,” said Dr. Mukerjee, assistant professor of clinical pediatrics and director of Immigrant and Refugee Health, Section of Community Pediatrics and Immigrant Health at Tulane University School of Medicine.

In a recent case, a patient family came to a clinic after being threatened with eviction. They had no income for months after the father was detained by U.S. Immigration and Customs Enforcement. Although the mother found employment, she had to stay home due to the pandemic. Ineligible for the Supplemental Nutrition Assistance Program, the family was without formula and food. The clinic was trying to connect them to resources such as the school district’s lunches for children.

“We’ve been following the family for a long time; now the situation is so much more dire,” said Dr. Mukerjee.

Normally, the providers can rely on a robust support system of social workers, school nurses and others. With school out, that link is gone.

“We are walking the line between two worlds,” Dr. Mukerjee said, “trying to do the best for our patients and advocating for their comprehensive needs …”

Overall, her patient load has dropped significantly. Dr. Mukerjee wonders, “Do they know we’re still here, that they can access care? Are they worried about cost?”

Dr. Mukerjee also is filling in as program director of the pediatric residency program.

Some residents are frustrated that they can’t do more to help on the front lines. Dr. Mukerjee reminds them not to overlook their contributions. That includes providing guidance to parents, giving advice on how to talk with children about their fears and advocating for children’s access to resources like food and social supports — “just like we do every single day.”

Anne Hegland, Carla Kemp, Devin Miller and Alyson Sulaski Wyckoff contributed to this report.

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