By Shoshanah Marcus, Staff Writer
One night, as I was opening my refrigerator mindlessly searching for food, my dad came into the kitchen. As I greeted and expressed my feelings about my social distancing dilemmas, I noticed that he was still wearing his scrubs and stethoscope. When I asked why he wasn’t in more comfortable clothing, he answered that he was going back to the hospital to work in the COVID-19 Intensive Care Unit (ICU). I realized that my sulky attitude was based on completely different circumstances than my father’s drained demeanor. Every day, he sacrifices his own well-being to tend to those who many health officials cannot or, even worse, refuse to treat. I conducted the following interview and believe his insights are critical to gaining a deeper understanding of the global pandemic.
Shoshanah Marcus: Please introduce yourself, your educational background, and your experience in the medical field.
Dr. Jonathan Marcus: My name is Dr. Jonathan Marcus. I am a board-certified Pulmonary Critical Care Physician currently working as an intensivist in Delray Beach, Florida. After graduating Yeshiva University in 1996, I studied medicine at the Rutgers University Robert Wood Johnson Medical School and became board certified in Internal Medicine, Pulmonary Diseases, and Critical Care Medicine. I have been practicing now for 12 years. For 10 of those years I was the Chief Medical Officer at the Hospital Corporation of American (HCA). I left in 2018 and have since been working at Delray Medical Center as a Cardiovascular Critical Care Intensivist, a Neurointensivist, and a Medical/Surgical Critical Care Physician. I also ran the Critical Care rotation at University of Miami-JFK campus for 10 years, have been involved in academic medicine, and have worked as a national consultant on the development of critical care programs in over 80 programs.
SM: What does your average workday look like?
JM: I get up at 6 a.m. and daven. I usually work 12-hour shifts, but I can work upwards of 36 hours on a given basis. When I get to the hospital, I begin by rounding on pre-existing patients in the ICU. I see all the existing patients, develop a plan of the day, write notes, and submit orders in the computerized electronic order entry system. From about 9 until 10:30, we have multidisciplinary rounds, which means that as a group, the doctor(s), the nurses, the therapists, and the case management team move from bed-to-bed in the ICU, talk about the plan and what it’s going to take to make the patients well again.
SM: How has your schedule changed since the outbreak of COVID-19?
JM: We normally have five ICUs in the hospital which has about seventy beds. When the pandemic broke out, we quickly assigned several of the units to be our COVID-19 ICUs. They were given the proper equipment and put in isolation. Normally we have two doctors in the ICU and a nurse practitioner or a physician assistant. We assign one of the physicians to be in charge of the COVID-19 patients and one physician to be in charge of the non-COVID-19 patients. In terms of workflow, in the last month pretty much all of our care, 80% to 90%, has shifted towards COVID-19 patients. We still get medical cases that come in, but the sheer volume of COVID-19 patients has been our priority.
SM: What is the situation like in the hospital? Do you have enough supplies?
JM: At one point we had 30 COVID-19 patients in the ICU. Most of these patients are on life-support, meaning they are on mechanical ventilators, they are sedated, they are on dialysis, and some of them are on bypass machines (ECMO). The only doctors allowed in the rooms are the ICU doctors, to ensure that our care efforts are streamlined to eliminate an excess of opinions. It’s not physically possible to be there the whole day because of the workload and protective equipment can become extremely uncomfortable.
We currently have enough supplies. At one point we were running low on protective equipment and mechanical ventilators, but when patients died or were taken off, they became available once again. At the beginning, it was unclear how to manage these patients and we were using up a lot of supplies and therapeutics on patients [who] were suspected to have COVID-19. Now we have more policies in place [in] terms of how we screen people, and how to best allocate our limited resources, so things have improved. Right now new cases have slowed down a bit, but we are anticipating a potential surge in the summertime.
SM: What do you think about those who deny the severity of this virus?
JM: At the beginning of the outbreak, there were a number of renowned infectious doctors [who] weighed in on the potential impact of the virus during our weekly meetings. My colleagues [who] went told me that according to the presenters, the coronavirus was not a major thing and the media was sensationalizing it. I have other non-critical care doctors that have made statements on whether or not therapies work and it seems that everybody has a different opinion. It’s easy to have an opinion when you’re not there at the bedside. Clearly it’s a very serious disease. I think we’ve underestimated the contractibility and the reproductive rate. I can tell you that the patients we’re seeing in the hospital do not behave like patients with influenza or similar pathogens. They tend to deteriorate very quickly and require high levels of life support and then, even when they recover, their lungs are incredibly scarred. They usually need some kind of assistance whether it’s a non-invasive assistance, invasive assistance, or oxygen and it’s taken quite a toll on the whole community.
SM: When should someone be tested for COVID-19? At what point should someone go to the hospital?
JM: If someone has symptoms — fever, dry cough, or shortness of breath — they should be tested. The reason why people should be tested in general is to confirm a diagnosis and to really ensure that they have the appropriate care and protective isolation measures in place. Initial data and descriptions of the viral infection suggested that asymptomatic patients were not as capable of transmitting the virus, but we know now that’s not true. If someone tested positive and they have mild symptoms they can be cared for at home by keeping them quarantined in a designated, well-ventilated room, while being treated with the appropriate medications and ensuring adequate fluid intake. If someone has worsening shortness of breath they immediately seek evaluation and treatment at the nearest hospital. For a patient [who] is asymptomatic but exposed to other people, it is still a good idea to get tested because they may be carriers and could transmit the virus to somebody else. So you have to make sure you’re constantly washing your hands and being precautious.
SM: How has your medical training prepared you for an epidemic of this magnitude?
JM: The field of Critical Care Medicine is unlike any other field because you have to have proficient knowledge of all areas of medicine including medicine, surgery, OB/GYN, in some cases Pediatrics, and Infectious Disease. The field lends itself to critical multi-organ failure and the management of life support systems. During my training in New Jersey, we had specialty training for pandemics because of the concern of biological warfare after 9/11; so we were used to the concepts of triage, allocation of resources, setting up command centers, backup strategies for ventilators, and how to deal with large volume. Because it was part of my training I’ve had a leg up in how to face this pandemic. I am so fortunate to work with a terrific group of doctors and nurses; we work incredibly well as a team.
SM: How do you think this will impact the healthcare system?
JM: I think ultimately the healthcare system is going to change. I’m hoping that there will be more communication and coordination between healthcare facilities, hospitals, and networks. I think the manufacturing companies that supply medical equipment should have more affordable platforms that ensure appropriate access for critically ill patients. I think the hospitals that do not have an efficient system are going to struggle the most. I hope it teaches healthcare providers to be much more directed and deliberate, to cut out unnecessary studies, and, hopefully, to award quality and efficiency over volume and productivity.
SM: When do you predict that we will be able to leave our houses? Is there an end in sight?
JM: Epidemiologists have built and presented multiple predictive models with different conclusions. Restoring our freedom of movement, the economy, and our “normalities of life” would have to be balanced over the risk of contracting and potentially transmitting the virus. My guess is that this would occur when the spread of illness and presentation of new cases would have to completely stop. Borders would likely remain closed until this has been assured. If people practice proper hygiene and use the protective equipment, then it is possible that these restrictions can be lifted a little bit early.
SM: With #HealthcareHeroes trending on social media, how do you feel about being called a hero?
JM: I’m usually too tired to think about it, but it’s very nice. It’s rare that critical care doctors get thanked. We are there when the patients are on life-support and sedated. When they get better they leave the ICU and we don’t usually get either credit for it or thanked, but that’s okay we can be there as the hidden knights in armor. I think all healthcare providers are heroes. We do it because there is no one else [who] can do it. But it feels neat. I wish I was more awake and had more energy to really enjoy it.
Photo: Dr. Jonathan E. Marcus in the ICU
Photo Source: Shoshanah Marcus