Daniel Horn is a physician at Massachusetts General Hospital in Boston, where he is helping lead a team charged with planning for the influx of coronavirus patients. His hospital is one of the best in the world, with enviable resources and a world-leading assemblage of talent. Yet Horn has been carrying an acute sense of dread about the coming onslaught that his institution, and others in the area, will soon face. He wanted to talk with me after watching the residents of his upper-middle-class neighborhood continue to congregate in coffee shops and restaurants.
Franklin Foer: Have you had to fully gear up with the gown and goggles and gloves?
Daniel Horn: I was seeing a patient for his routine annual exam last Tuesday. And my medical assistant came up to me and said, “This patient has a cough and we just received the instruction about wearing personal protective equipment. What do you want to do?” Things were moving so fast that I had to read the guidelines. They are changing day to day. I realized that I had to put on kind of all the gear to go evaluate this patient. And I walked in the room—this poor patient, who just simply had a winter cough, his eyes went wide. He immediately asked to leave. His blood pressure went up 60 points just from seeing me in the gear. And that was not a situation I have ever wanted to be in. But that is the situation right now.
And so we are rapidly shutting down routine care. We have canceled all planned follow-ups with patients with diabetes and heart failure at this point because we have to preserve that personal protective equipment.
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Foer: So what are you seeing now?
Horn: All over Boston, we’re hearing reports that the number of visits with possible coronavirus cases has started to hit that exponential-growth trend. We were at 10 to 15, recently up to 30 to 40, and now yesterday there were some 129 visits or something like that at our surge-testing clinic.
Foer: I know you’ve been following the course of the disease in Italy …
Horn: That really set off the alarm bells. We began hearing earlier last week about wide-scale ethical dilemmas: Italian physicians having to choose which patient receives a ventilator. And the rapidity with which we heard that patients can’t get basic access to inpatient or outpatient care in Italy raised the concern that we weren’t even thinking about the pace and [overwhelming of the system] that coronavirus can cause.
Foer: Could the crisis here land even harder than in Italy?
Horn: I have to say that Boston is one of the places that did take rapid and important action last week, such as delaying the Boston Marathon, closing Boston public schools, canceling our Saint Patrick’s Day parade. But as I walked around my neighborhood here yesterday, I was shocked and concerned to see that our coffee shops were full of people, our restaurants were full of people having drinks and enjoying their time together. And it just showed me that I am carrying a burden of seeing what we’re doing at the hospital, seeing how concerned we are about what we know is coming. But my fellow citizens don’t see it. My personal psychic crush is that I’ve been walking around for the last week seeing what’s coming and feeling somehow unable to share that clearly and effectively with friends, family.
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Foer: How close are we to zero hour? If we don’t do extreme social distancing in the next day or two, what do you think Boston hospitals are going to start to see?
Horn: What we’ll start to see are primary-care practices jammed up with calls, because calls with worried patients take a really long time. Then the really worried, scared patient that doesn’t get through will unnecessarily go to the emergency department, which is already full. That clearly will create a major strain on emergency-department management systems.
And then the hospital fills with older patients with coronavirus with low oxygen levels that need oxygen support and IV fluids and help with nutrition. Suddenly we have multiple floors of those patients filling up beds. And then 15 percent of them begin to crash and develop acute respiratory distress requiring mechanical ventilation to save their life—all at the same time—and then we don’t have enough ICU beds and mechanical ventilators to manage the patients that are all crashing at the same time. We will be [grappling with] the types of ethical dilemmas that we really only see in wartime in this country.
We have plans for that. But we don’t want to have to have plans for that. The only way we stop that situation from developing, the only clear way, is that our entire society sort of voluntarily commits—that’s the individual, the corporation, the public institution, town leadership, state leadership, and federal leadership—commit to slowing that process down so that we don’t have all of those patients beginning to crash the ICU beds at the same time.
Foer: I know doctors spend a lot of time thinking about the ethics of rationing care. How does it feel to go from academic exercises to the real deal?
Horn: My mood vacillates. Leaders have not stood and told people exactly what they need to do. But also, I’m filled with hope and inspiration about what we’re doing to get ready for this. We’re actively redesigning our whole health-care system to accommodate patients with other upper-respiratory illness and suspected coronavirus.
Foer: What does redesigning health care on the fly look like?
Horn: We are trying to rapidly deploy virtual-care capabilities—with regular phone and video check-ins—to all of our physicians, starting with physicians who care for our most complex or highest-risk patients, patients that we want to keep out of a health-care setting right now, like patients who are immunocompromised, patients who have had transplants, patients who have cancer. If we can keep them out of health-care settings and move them to video-based care immediately, we know we will save lives. Of course, there will be programs like you’re seeing working in Hong Kong and in South Korea, where we can start doing rapid mass testing to start guiding people who need to be home and who can be out in the workforce.
Foer: Is there a sense of foreboding among the staff of the hospital?
Horn: The truth is, I don’t think I’m ready to comment on that, because of our internal policies. But to stick to the thesis here: Aside from not overwhelming our emergency rooms and ICUs, the main reason for comprehensive social isolation right now is because if you expose a health-care worker to the coronavirus and that becomes a documented exposure, they will not be able to work for 14 days. And if they are not able to work for 14 days, then we will not have a health-care workforce to take care of you. That’s the key point there.
Wajahat Ali: Where are the masks?
Foer: Doctor, can you help resolve a question that has emerged in my household today? My family was talking about going on a hike or walk with another family. Is there a way to do that safely, or should that all just be shut down right now?
Horn: I think outdoor space … I think being outside will be really crucial through this period of time—getting fresh air, getting exercise. I think that even in that context, I would advise that people still try to stay three to six feet away from each other, and certainly don’t do an activity like that if they have even a mild cough or cold.
The issue with this virus that diverges from things like SARS and some of the most scary recent pandemics we’ve seen is that this virus is clearly shedding for four to five days before patients become symptomatic. And in fact, we have a lot of signals that even when patients become symptomatic, things like fever may not be present early on in the course of the illness. And so at this point, if we really want to slow transmission, people need to completely socially isolate from others outside of their nuclear family.
Foer: I see people going into Starbucks still—and have heard someone justifying ordering on a mobile app. Are they wrong?
Horn: Corporate leaders, such as owners of chain coffee shops, chain restaurants, bars, should stand up now and say, “We are voluntarily closing, to help flatten this curve.” They need to buy time for the curers and innovators who are leading the hospital- and health-care-system response, so that they can get their plans together and be ready for this. That will make a huge contribution to this country not going through what will be a profoundly traumatic experience over the coming months.
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