As the health ambassador for Manchester Essex Regional High School, I seek to raise awareness about issues that impact the health of our students and community. I recently spoke with Massachusetts General Hospital Emergency Department physician and local resident, Dr. Kimo Takayesu, about how COVID-19 has changed ER care, antibiotic resistance and how real life as an ER doctor compares to how it is depicted on television.
Q: Welcome Dr. Takayesu, can you please tell me about yourself and your practice of medicine at Mass General Hospital?
A: In my role, I spend half of my time doing direct patient care in the emergency department and half of my time training emergency medicine residents. From a clinical standpoint, our ER sees about 100,000 patients per year, so it’s a busy place. We're what's called a Level I trauma center, burn center and pediatric trauma center -- so, we see everything. As is standard for emergency medicine, I work about 3-4 shifts per week, taking care of all patients from adults to pediatrics. The remainder of my time is spent running simulation training programs and supporting wellness programs for my department.
Q: What are your thoughts about how the COVID-19 situation may result in long-term changes to the practice of emergency medicine?
A: The healthcare system leading up to COVID has led the ER to become a very overcrowded environment, which is frustrating for both patients and providers. When we had to think about infection control because of Covid, we knew we had to reduce overcrowding. Our hospital successfully responded by quickly creating capacity in our inpatient beds so that we could move patients out of the emergency department to be able to care for all of the newly-arriving patients who needed respiratory support, often including some form of ICU-level care.
When I think about what is hopefully the soon-to-be aftermath of COVID, we will likely see the return of overcrowding in our emergency departments. We're regressing a little bit back to business as usual, which I think is an unfortunate reality of modern healthcare. But I do think the pandemic has refocused us on the need for preparedness, the need for our public health infrastructure to be strong and for it to be well-funded.It has shown us a lot of the gaps in our healthcare system. I'm hopeful that some of those efforts towards preparedness, community health and outreach will continue now that they've been highlighted during the pandemic.
Q: I'm curious about how the clinical case mix has changed. Are there conditions that you've seen a lot more or less of during this time that have surprised you?
A: Yes, that was one of the strangest things about COVID. For several months, we were wondering where all the patients went because our emergency department volume went precipitously down -- to about 50 percent of the number of patients we normally see. For conditions like appendicitis, heart attacks, strokes, I actually went about 8 weeks without seeing these illnesses in the ER. In June and July, those patients started to return, and it was clear that some patients had been suffering through these illnesses at home, because they were presenting with some of the delayed complications of illnesses. This was likely due to people being afraid to come into the emergency department due to COVID. As far as the flu, the influenza season was a relatively mild one for us. Much of that was due to good infection control through wearing masks and staying at home, and also to making sure everyone got flu shots. I know that I haven't been sick since January, 2020 -- I've never gone that long without being sick!
Q: Off the topic of COVID, I researched ER care and chest pain is one of the top reasons why people come to the emergency room. For our readers, do you have guidance on what chest pain symptoms warrant an ER visit?
A: When it comes to chest pain, we worry about a heart attack among other serious conditions. If you have a family history of early heart attacks, meaning heart attacks in your mother, father, sister, brother, aunt or uncle before age 65 for females and age 55 for males, you may be at increased risk for coronary artery disease. The things that worry me are if you're so short of breath that you really can't do normal activities, if you're fainting or feeling very lightheaded, if you have a sensation of heart racing, or palpitations, sweating, or vomiting in combination with chest pain. In general, the combination of worrisome symptoms plus of family history are what we look out for. Fortunately, most of the time there end up being only a handful of patients who end up having something dangerous, but for the public’s health, we encourage anyone with worrisome symptoms to have a medical evaluation.
Q: I want to talk a little bit about antibiotic resistance because I just read the book “Superbugs”, which raised the concern of patients asking to be prescribed antibiotics. Is this something you've experienced in the ER? And what are your thoughts more broadly about antibiotic resistance?
A: Certainly, antibiotic resistance is a continually-evolving problem. I see that when people feel sick with bronchitis in particular, when someone is coughing for weeks on end and not getting much sleep, there is a point when people ask [about antibiotics], as in, "Is there something that I can do to help me feel better?" In those situations, we have good clinical guidelines about whether antibiotics might be helpful or not (typically, they are not).
Twenty years ago, the idea of a superbug was on the horizon and we were dealing with it in a very small number of patients who took a large number of antibiotics to treat chronic illnesses or infections. At that time, the concern was that these resistant organisms could affect patients who have no pre-existing conditions and could generalize to the larger population. Fortunately, books like “Superbugs”, combined with public health messaging, have helped to educate the public of the dangers of not just antibiotic resistance, but also of the side effects of antibiotics, including that they can make you feel sick or cause complications in their own right.
Q: You mentioned that the people who had these superbugs 20 years ago had taken many antibiotics, have you seen more cases in recent years?
A: Yes, definitely. When I first started in medicine, the idea of extensive hygiene protocols was in its infancy, using Purell between every patient and wearing gloves was about the extent of good practice. Now, there are so many different types of bacteria and different ways in which they're transmitted that we have specific guidelines around seeing patients who have had these infections and potentially carry these bacteria in their bodies. Fortunately, we can rescreen a lot of those patients, and retest them to see if they still have that resistant bacteria in their system, because sometimes patients clear the bacteria. Unfortunately, there's certainly a much wider array of bacteria that are resistant to multiple antibiotics than we had 20 years ago. We now have helpful programs like antibiotic stewardship, which is regulating what types of antibiotics we use as a first, second, and third in our course of action. Coupled with good culture testing, this can reduce the number of people getting any given antibiotic, which in turn reduces the development of resistance within the bacterial population that we all live with.
Q: To wrap up, can you tell me what people would be surprised to learn about the life of an emergency medicine physician?
A: I think that one of the surprising things is how much the ER is oriented to primary care. People have an image of emergency medicine based on the TV shows, where everything is exciting and there's always some disaster that's about to happen to a patient or to the emergency department. I'd say our life is much more like [the tv show] “Scrubs”. There's a lot of emergency clinical care that we do, but I think emergency medicine is also about being a safety net for society. We see a lot of patients who are in need of primary care and they're coming to us because they either don't have a primary care physician or they can't get an appointment with their doctor soon enough to address the kind of need that they have. It's not all defibrillating patients in dire situations -- that's probably less than five percent of the job. But you see all types of patients from all walks of life, which is why it is exciting. There’s always something new every shift.