Caring in the Time of COVID

By Kevin Tankersley

Q&As with three heads of hospitals

Hospitals have been on the frontlines of the pandemic for almost a year. Local health care facilities have had to adjust quickly as one challenge arose, only to be faced with another. In every situation medical professionals have adapted and found ways to provide safe, quality care for patients while protecting staff.

Wacoan writer Kevin Tankersley visited remotely with the heads of three hospitals: Dr. Brian Becker of Ascension Providence Waco, Dr. Diedre Wuenschel of Coryell Health and Dr. Umad Ahmad of Baylor Scott & White – Hillcrest. Each physician gave credit to the health care heroes in their facilities, who press on despite tremendous strain.

Dr. Brian Becker
Ascension Providence Waco
“I knew we had good health care in this community. But I didn’t realize the collaborative approach that everyone would take as we faced a pandemic.”

Dr. Brian Becker is the chief operating officer and chief medical officer for Ascension Providence Waco, roles he has held for nearly five years. For the 20 years before that he operated an OB/GYN practice in Waco. He has degrees from the University of Texas at Dallas, the University of Texas Medical Branch at Galveston and Baylor University.

WACOAN: I assume you and your team have been busy over the last 10 months or so.

Becker: Yes, that’s correct. It’s been really since the beginning of March that we’ve been under a little bit of pressure from COVID. And through that time, we’ve had, I guess, a couple of surges. And quite honestly, I have insight into what’s going on with the other Ascension [facilities] in Austin, and Waco has been a bit of an outlier. Our community has really never recovered from the surge we had in the summer. It’s just been a steady drumbeat since summer. And certainly now we see a rise on top of that number even, but we never got a reprieve from our summer surge.

WACOAN: Can you point to any particular reason why Waco has been an outlier?

Becker: I wish I could. I think the easy answers are we don’t do as good a job of policing ourselves when we’re out in our community. But when I’m out, I don’t see a tremendous number of people walking around with no mask. I see most people following the rules that have been put in place.

We do see clusters in families. And I think we’re in a community where family’s important, and people hang out with their family unit, whether that’s grandmothers and grandfathers — it’s extended families here. And maybe that’s what’s driving more [cases] for our community. It’s a strong sense of family here. And I think that when we see a person get infected in a family, we oftentimes see multiple members of that family get that infection as well.

WACOAN: I’ve heard of people who have intentionally tried to catch COVID after someone else in their house already has it, so they can get it cleared out. Is that a good idea?

Becker: So first I would suggest that that’s probably not the best way to handle things. The old ‘chicken pox party’ is probably not the best way for folks to try to beat this disease. Some people get sick, and some people don’t. A lot of people don’t get particularly ill with this. But those who do can get really sick.

I think there’s a couple of days where people don’t realize they have COVID, two or three days. They were exposed and picked up the virus and are sick, but they just don’t recognize it. And then they start to develop some symptoms. And typically what we’ve seen is it’s seven to 10 days after they start developing symptoms that they really start getting sick. So if I add that on top of a couple of days, it could seem like two weeks after my exposure before I was sick enough to feel like I needed to get in and get checked out.

WACOAN: What’s the biggest challenge Ascension Providence Waco has seen?

Becker: I think that’s evolved over time. Initially it was just making sure we had adequate supplies for everything. When this all started, I think it was obtaining personal protective equipment — masks, gowns, respirators, N95 masks, just the stuff that we needed to take care of these folks. Being part of a large national organization who has purchasing power across the globe, we really never suffered too extensively with that. We might have been short on-hand here in the hospital, but with an ask we could have it within a day. We were never as much in a pickle as some smaller facilities or independent offices found themselves.

I think recently it’s been more about people, just having enough people, meaning laundry staff, nutritional staff, cleaning staff and, most importantly, nurses and respiratory therapists. It’s having enough of those people to manage the volume of patients that we’re seeing. For a period of a couple of months in there we were working our staff pretty hard. They were gracious, and they pulled extra shifts, and they filled the gaps and met the need.

In the last two or three weeks now we put in a request for federal assistance. We received some FEMA nurses, some STAR assistance [State of Texas Assistance Request], and we got nurses from both of those venues, both nurses and respiratory therapists, who have allowed us to really be adequately staffed without overworking folks in the last couple of weeks. That’s been a huge help for us. So probably for me, if you asked that question, the biggest thing was people. It’s just having enough trained staff to manage the needs day to day.

WACOAN: Has your hospital faced an issue of having enough space for patients?

Becker: We have over the last month. Prior to that we were using our licensed beds. Every hospital is licensed for X number of medical surgery beds, ICU beds and so forth. And until about four to six weeks ago we were staying within the confines of that license. In the last month, month and a half, we have begun to exceed the capacity of both our ICU and our medical surgical beds. And so we have begun to expand into areas that are capable of managing these patients but not routinely areas where we house these patients.

An example would be a recovery room after surgery. We have a large recovery room, and patients come out of surgery, go there for an hour or two, and then they move on to wherever it is they’re going. Those beds are all capable to manage an ICU patient. They have all the appropriate monitors. They have all the equipment needed to manage an ICU patient. So we have expanded ICU care into our recovery room.

So now I take an ICU nurse and put her in the recovery room taking care of two or three patients. And we expand that in sort of a pod setting. And over the past week or two we’ve consumed almost all of our recovery room with ICU patients because our ICU is full. We continue to grow and adapt, and we are continuing to take care of patients. They come in with a need, and we address it, and we take care of them. We haven’t had a real need to turn any patients away or refer them elsewhere or transfer them, but we have had to expand.

In the same sense our medical surgical units have needed to expand into our outpatient services area. We have 25 beds roughly in that department that typically don’t have admissions in them. They have patients that check in, in the morning, get ready for whatever their procedure is, and move on to the procedure. But we have been, for the last week and a half now, been holding in those beds and in those rooms what would typically be in one of our medical surgical rooms. And for us, that falls in our surge plan. We had a plan on how we would optimize our normal beds and then begin to expand into areas where it’s normal for us to do that type of care but not routine.

And then our third level is really areas that we don’t normally house patients in or deliver care in at all. And that’s a surge level three plan. We have begun to flesh that out and have most of the details worked out if we need to expand into that. That’s our next step.

WACOAN: What is the space where you don’t normally have patients?

Becker: An example would be our teaching and training area. It is an area that is set up very much like a normal hospital setting. We work with mannequins and simulations, so we have all the appropriate pieces of equipment to deliver care. So that’s an easy thing — I can move the mannequins out and put real patients there. That is an area where we normally wouldn’t be taking care of patients but are capable of doing so. So that’s a good example of where we could deliver patient care and expand pretty easily.

WACOAN: Elective surgery is on hold. Is that right? Was that a state mandate?

Becker: That comes out of the governor’s Executive Order 31, I believe. [Governor Abbott’s] EO 31 and 32 spoke to hospital care and really hinges on the trauma service area. We’re in Trauma Service Area M, which is five counties, McLennan being central in those five counties. And per the governor’s order, if we are over 15 percent for hospitalizations of COVID patients in our five-county area, then that order becomes effective for us. We’ve been in that realm since mid-November.

From a hospital standpoint, it specifically says we cannot do elective surgeries. We can do emergent and urgent surgeries. We cannot do elective surgeries unless, in so doing, it wouldn’t deplete our ability to take care of COVID patients. I could do an elective case if it wasn’t going to use up personal protective equipment, or it wasn’t going to take a hospital bed that I needed for a COVID patient. We can still do them.

Having said that, we are now about six weeks into not doing any elective cases here. We recognized early on that one resource that it was going to deplete was nurses, someone who could be at a bedside, taking care of a patient. We really need nurses. By cutting back on operating room activities, I can redeploy some of the staff in our operating room to other areas of our hospital to assist in patient care. That was our initial driver. And then as we began to get assistance in nursing and respiratory therapy from the state and federal governments, then we began to get into things like running out of beds in our facility, using up some of the recovery room for ICU. It transitioned from us needing [medical staff] to now not really having space. We simply have not been doing much in the way of elective surgeries for the last six weeks.

WACOAN: What all falls under the category of elective surgery?

Becker: I think it’s probably easier to define urgent and emergent than it is to define what’s elective.

If you show up with an acute appendix or an acute gallbladder, or if you’re having a heart attack and you need a procedure done in our cath lab or in our [operating room], those would all obviously be things that we that we will continue to do. Those are routine, emergent things that need to happen.

If you come in with a fracture and it’s set in our emergency room, but you need a surgery to put a pin and a plate in, well, that’s an urgent thing that needs to happen in pretty short order after that visit.

Elective things would certainly be things along the lines of plastic surgery, cosmetic plastic surgery, some of our eye surgeries, cataract surgeries — certainly an inconvenience and a life-changer for patients who are experiencing problems with cataracts. But there’s not anything that’s life-threatening or limb-threatening in those cases.

We consider a delay in diagnosis of cancer or delay in cancer treatment as not elective, so we are continuing to do those procedures that revolve around cancer. And then renal patients who are on dialysis — their access point for that dialysis is not considered elective. Addressing those issues still are significant and important.

That is a long-winded, roundabout way of trying to give you at least some snapshot. We have put in place a process for our physicians, our surgeons, and this doesn’t just apply to our operating room. It’s our GI lab, where colonoscopies and esophageal studies are done, pulmonary studies, our cath lab and then our interventional radiology, where our radiologists perform some procedures, such as biopsies. Those all fall into this same arena.

And we have seated a committee of physicians who review a list of cases that wish to be scheduled in the coming day or two or three. And we look at that list. Our physicians are submitting a piece of paperwork that says this is urgent, this is emergent, or this is elective, and we’re reviewing and approving each case before it’s getting on the schedule.

WACOAN: Along the lines of bringing those physicians together, how are COVID and hospital protocols determined? Is it a committee? Does it come down from home office?

Becker: I think it’s multiple pieces. I will tell you that a great deal of guidance on managing COVID-19 really is driven by the CDC and the guidelines that they put forward, so I think there’s a great deal of uniformity across the country in what a lot of hospitals are doing because it’s driven by CDC directives.

For us, particularly, we have Ascension national, and Ascension national has a team that puts out directives that indicate what’s best practice, for both management of disease from a clinical standpoint but also in operations of the hospital, what should we be doing?

We have a Texas market leadership team who has input in what we will do here in Texas. What we see in Texas may not be the same as it is in other states. We may have needs that are different.

And then down to the community level. Every community is different, and this hospital serves this community. So as I said, since mid-November, we have been a service area where we’ve been over 15 percent [hospitalizations from COVID]. Austin just reached that over the weekend. We have been functioning in a different environment than Austin for the last month-and-a-half.

And then ultimately, at the end of the day, it’s the hospital board that approves all of these protocols or procedural changes that we put in place. There are a great deal of decisions that are also still made locally.

I would tell you that it’s probably fairly uniform across most hospitals. But that’s the pathway for us.

WACOAN: How do nurses and respiratory therapists go about working with COVID patients? Is one nurse assigned to a patient? Are you trying to limit the number of people in and out of the room?

Becker: We do exactly what you said. We try to limit the number of people that are in and out of a room and limit our associates’ exposure potential.

From the very beginning we began to co-locate our COVID patients. We had a portion of our ICU that was easy for us to use. Our ICU is set up in pods of 10 beds each. And we started out with just a 10-bed unit of COVID patients, one unit in our hospital. We’ve certainly expanded from there. But we are still making every effort to co-locate COVID patients so that they are in a single area or at least a contiguous area.

We do limit the in-and-out of a nurse. Typically a nurse will be in and out of a room hourly, checking in on a patient. We’ve scaled that back. It may not be a visit in the room. It may be a phone call into the room to check on the patient, if that’s amenable and the patient can respond appropriately.

[Environmental services], EVS, our cleaning folks, normally clean regularly in each room throughout the day and then maybe once a day in a COVID patient room. Every effort to reduce the number of people in and out of the room and to limit the exposure for our associates and still provide high quality care for that patient, that’s what we’re trying to do.

WACOAN: If a patient with COVID is in your hospital, then that patient can’t have visitors? Is that correct?

Becker: That’s correct.

WACOAN: What about if a visitor has tested negative or had the vaccine or already had COVID and recovered?

Becker: Certainly one of the most disruptive things that we’ve seen through this, from a public standpoint, is our visitor policy, which for a while was no visitors anywhere. And then that was relaxed a bit to one visitor. And for our COVID patients, no visitors unless there is a significant change in their condition. If they’re sick, if they’re going to be moving to ICU and they may be intubated, then that’s a significant change in their clinical picture. We certainly want to allow family to come in then and visit those people. Or if it’s an end-of-life point for that patient. If despite all our best efforts, this patient is going to die, we certainly want to allow family members in to visit those people. We do it in a very regulated, uniform fashion, but we do allow visitors to COVID patients in those conditions.

To the second part of your question, which was as we roll out vaccines and people are vaccinated, should they be safe to come in and visit? That’s the logical progression from the other part of your statement, of someone who has had COVID and [recovered] and assumed to be immune. It would be very difficult for us to regulate that process, to be able to confirm that someone had truly been exposed and had COVID-19. I don’t know if everyone who has COVID is subsequently immune. I don’t know that they can’t get it again. There have been instances of people getting a reinfection. They’re rare, but not impossible.

And then, looking into the future, just the whole process of trying to confirm someone was positive and if they did get a vaccine. It becomes really almost impossible to police that at the front door. At the present time we are not allowing people, even if they say they’ve had COVID, we’re not allowing them in to visit someone on our COVID unit.

WACOAN: Have you noticed a drop in other cases coming into the hospital, like maybe older folks who are afraid to come?

Becker: I think there’s two points. One is good, that is this has been a relatively light flu season. And I think it’s because people were encouraged early on to get flu vaccines. Maybe more people got vaccinated. So that was great. People are also socially distancing, wearing masks, and so that’s limited the flu exposure for our community. We’ve seen far less flu this year than we’ve seen in the past, which is nice, because if we had flu on top of this, that would be really difficult to manage.

To the second part of your question, yes. We were restricted in our elective surgical cases for a period of time in the summer before we opened it back up. And we saw some reluctance on the part of our community to want to come into the hospital and have a procedure done because they were concerned about potentially contracting COVID. I think patients have self-limited. They are not showing up for routine stuff, things that we would normally see. Our [emergency department] volume is down pretty significantly. And I think that just speaks to patients having a reluctance to want to get out and come in for health care.

We do continue to urge people to manage their chronic disease. Folks with diabetes, high blood pressure, heart conditions — they need to continue to see their physicians. They need to continue to have care delivered, and when appropriate, continue to have procedures that are necessary. If you have something that you would normally come to the emergency room to treat, you should still come to the emergency room. You should come in and get it taken care of.

I think we’ve seen some diminishing of that state of mind over the last several months as we’ve gotten further and further into COVID. I think people finally realize, ‘Well, I just can’t keep pushing this out. I need to get it addressed.’

WACOAN: Let’s say somebody has to come in for one of those non-COVID procedures, a surgery or a broken bone or something like that. Do you test the person for COVID as they come in? If someone brings in that patient, do they get tested?

Becker: We do test all patients. For every patient who has a scheduled procedure, there’s a process whereby they’re tested somewhere from three to five days in front of that procedure, to make sure that they don’t have COVID. I don’t want an asymptomatic person potentially exposing a number of our staff to COVID infection. They’re all tested and asked to self-isolate in the interval between the test and the procedure.

For someone who arrives urgently or emergently, we don’t always have an opportunity or time to do a test. If we do — and we can get a test back within a few hours most of the time for those cases — we will test if it’s at all possible. If it’s not possible to test, if someone steps into our facility and needs to go immediately to a procedure, we manage those patients based on symptoms. If they have any symptoms, we treat them as if they’re positive. And if they’re not able to be responsive for us to determine if they have symptoms, we manage them as if they are positive. Just by default, we assume the worst so that we can protect everyone involved.

Your question about visitors, we do not test visitors. If you have a family member that you’re bringing in for a procedure, we do not test those family members. We have a universal masking policy in place where everyone in the building has to wear a mask. And so while we are not testing those visitors, we are mandating that they wear a mask, which should reduce any potential for exposure in the facility.

WACOAN: Do you see any permanent changes in the ways that hospitals operate, post-COVID?

Becker: I’ve been in this role for over four years now, as a medical officer. That was kind of an easy transition for me, from private practice to that, and then more recently into operations. And so I don’t know that I have a great deal of hindsight. I don’t have a lot of looking back to see how things were done.

I look at all the things that have changed over the last year, and we’ve made some pretty substantial changes, I think. And one that is probably true across multiple industries is the fact that people work remotely. We have a number of people that are still working remotely for us. Their presence in the building is not required. The job they fulfill can be done from anywhere. And we can communicate via Zoom or a Google Meet, just like we’re doing here. That functions very well. I think, probably, as I say, with most industries, people are looking at, ‘Do I really need you here on-site to do this task, or can we do this remotely?’ I think that’s probably not going to go away. We will continue forward with some pieces of our infrastructure working remotely. That’s probably one.

And then a second that I’m just guessing may be impacted: Hospitals, from a cost standpoint and trying to be efficient, really keep only a few days of everything on hand. We don’t have stockpiles of stuff sitting around. That’s a huge amount of capital tied up in those kinds of things. It’s a lean process. And when this all began people were scrambling for stuff because you had only two- or three-days’ worth of stuff on hand. For us, being in Ascension [national network], it was a little easier to acquire it. But still it may change people’s idea on what is critical and how much of that should I have on hand. That may be something that we look at a little more closely going forward as well.

Operationally I don’t see a whole lot of change from a care delivery point of view. We have been stretched, and we have been asked to be flexible. Our nurses, our respiratory therapists, our associates in the hospital, across campus and in our clinic system, as well as our physicians, have demonstrated remarkable ability to flex to whatever the ask is for today. That’s probably been pretty uniform for forever in hospital settings.

We have seen nurses that have transitioned to new areas, taking care of patients that they didn’t previously. Nursing, much like the medical field in general, is very specified. I have nurses who work in the operating room. I have nurses that work in ICU. I have nurses in the labor and delivery, in the emergency room. They’re very focused on their body of work. And early on, in April, we retrained almost all of our nurses so that they could function in a medical surgical unit and take care of a standard inpatient. Maybe that ability to cross-train nurses to cover across multiple units is something that carries forward as well, so that we can plug and play people in multiple different roles as opposed to being so focused on a specific area.

WACOAN: Is there anything else I need to know that I haven’t asked you?

Becker: I want to thank our staff, whether it’s our associates in the hospital or in our clinic system, our independent physicians, all have done a tremendous job. And early on in this there was a whole lot of talk about health care heroes, and a whole lot of thanks given to these folks. And as it wears on, everybody gets tired. So I just want to continue to put those people in front and up top. They’re doing the lion’s share of the work every day, and I want to say how much I appreciate what they do for us.

Secondarily is our community. Our community is a strong community. And from day one Ascension Providence, Baylor Scott and White – Hillcrest, our health department, our city and county officials and Family Health Center, have all sat around the table multiple times of the week, each and every week since March, and have had conversations on what’s best for this community. It’s not about what’s best for each of these individual facilities. It really has been focused on delivering great health care in this community. I couldn’t be more proud to be part of this community that puts community first and the tremendous amount of work that’s gone into that process.

It has been an eye-opener for me. I knew we had good health care in this community. But I didn’t realize the collaborative approach that everyone would take as we faced a pandemic.

Dr. Diedra Wuenschel
Coryell Health, Gatesville
“I don’t really see telehealth going away. I think lots of people have liked that. I think even some of the technology of text messaging and things like that are going to stay.”

Dr. Diedra Wuenschel is the chief of staff at Coryell Health in Gatesville. She also holds down the positions of medical director for RehabLiving at the Meadows, medical director of the Coryell Health Medical Clinics in Gatesville and Mills County, and she is the director of the Coryell County Health Authority. She also has a full-time family medicine practice. Wuenschel has been with Coryell Health since 2011. She’s a graduate of the University of St. Thomas, Texas College of Osteopathic Medicine and the University of North Texas Health Science Center in Fort Worth.

WACOAN: I assume you and your teams have been pretty busy over the last 10 months or so.

Wuenschel: Oh, yes, definitely. We’ve been seeing lots of patients. We’ve been testing lots of patients, doing car visits, doing telehealth visits and making plans for how to keep everybody safe, how to keep the nursing home safe, how to keep employees safe.

Starting back in March, we had never done telehealth here at Coryell Health, and I believe it was March 19 when we did our first telehealth visit. Within a week we were able to start doing telehealth visits and to help our patients and to keep them safe.

And we immediately started coming up with plans on screening our employees as they come in the door, screening our patients as they come in the door. We take a temperature on every person that walks in the building. We place a mask on everybody that walks in the building. We’ve taken chairs out of our waiting areas to ensure that there’s social distancing throughout the entire facility. We’ve done car visits, so people who have any symptoms that are coming to our clinic, we actually go outside and see them so that they’re not exposing other people whenever they do come into the facility.

WACOAN: Telehealth, meaning appointments via Zoom?

Wuenschel: It’s very similar to Zoom. We use a program called QliqSOFT. It sends a secure message to the patient, and then it has a secure link.

And so we also, over the last few months, just with the amount of people that are being tested, and the amount of increased positives that we’ve had, we’ve used that same program to be able to send a text message to people to tell them when their test results are negative and a text message to check on their symptoms. Nowadays people don’t really like talking on the phone — they would rather text. So even when we’re checking on the patients to see how they’re doing throughout their 10 days of quarantine, they’re able to just click and tell us what symptoms they’re having, whether or not they’re getting worse or better. And they don’t have to be annoyed with a phone call and talking to us.

WACOAN: You talked about keeping everybody safe. What are the safety protocols in place at your facility?

Wuenschel: We have multiple different parts within our facility. We have a nursing home that’s attached to us. We have long-term care. We have independent apartments, and we have the hospital, and then we have the clinic. In the past we may have had a nurse that would work in [multiple] departments, going back and forth. And so we’re making sure that nurses that are working with the COVID patients are not going into our rehab living area, the nursing home area. That’s one way. Those patients aren’t able to leave, and especially at the beginning they weren’t even able to have visitors. So we’ve done that, where we kind of separate out the employees to make sure that we don’t have somebody who’s working with COVID patients going to somebody that is a non-COVID patient.

We check COVID status on our nursing home staff twice a week, and we’ve been doing COVID screening on our employees in the emergency room, within the clinic. Even our administration is getting tested at least once a month, again, to keep everybody safe, even if they’re asymptomatic.

WACOAN: Has space for patients become an issue at your hospital?

Wuenschel: Our biggest problem has been getting patients transferred. We are a smaller facility, so getting ICU patients transferred to the appropriate place where there’s appropriate physicians for them. We’re a small place, so we don’t have neurosurgery, and we don’t have interventional cardiology here. So when somebody has a heart attack, that’s been one of the more difficult things is trying to get them transferred to a larger facility with the specialists that are available.

WACOAN: I’ve read about some nursing homes where patients have been in their rooms since last March, with no social activities, no Bingo, no communal meals. Is that the case there, and how are you dealing with that?

Wuenschel: Yes, Bingo, of course, is always a big thing within the nursing home. And one way that we’ve dealt with that is we do hallway Bingo. Everyone stays at their doors, so they’re still 6 feet away, and we do it that way.

At first when everybody was eating in their room (which most are still), we were seeing some weight loss. We have large dining rooms that used to fit everybody in them, and so what we’ve done is for those patients who are able to get the dining room, maybe it’s five patients, they are seated more than 6 feet apart. But just seeing somebody else has helped them start eating. We’ve seen improvement in our weight loss by doing that, even if it’s social distanced meals, they’re still able to see somebody else.

And in the past, you know, we would have the residents within the nursing home dressing up and doing a [in-house] parade. We just kind of do the opposite thing now. We have the employees do a parade so that [the residents] can see them.

WACOAN: Say someone comes into the hospital with a non-COVID issue, like a broken leg. Can a family member come in with them? Do they get tested?

Wuenschel: What we’ve done whenever they come in for a non-COVID emergency, we still test them prior to being admitted into the hospital. And so if it’s something that requires admission, we would still test them. But then we’re also testing their friend or family member that wants to come visit — again, to keep everybody safe. And then coming into the emergency room, we’re obviously recommending only one person [besides the patient] at the most. But it’s at that admission time, when you’re admitted into the hospital for long periods of time, that we make sure that we test the visitor as well as the patient.

WACOAN: When the visitor gets tested, do they have to leave until the results come back?

Wuenschel: If we know that the patient is going to be here for an extended period of time, say, if they’re coming for knee surgery or something like that, [the visitor] will get tested with the patient. We are testing everybody preoperatively the day of the operation, so we’ll test their visitor at the same time. And so we’ll get those results. We do in-house testing, so we’re able to get the results within a few hours whenever we do that. And so it doesn’t end up being an extended time of days’ worth of not being able to visit. But with that we’ve caught people who are asymptomatic and within a couple of days do start to have COVID symptoms.

WACOAN: Has your hospital cut down on the number of elective surgeries? Wasn’t that a state mandate?

Wuenschel: We essentially are just looking at everything case by case. We do have enough supplies that we’re able to perform elective surgeries because that’s one of the caveats — you can’t perform them if you don’t have enough supplies. We don’t want to run out of supplies for COVID patients, but we have the appropriate number of supplies.

And we look at the patient. If they look like somebody that could possibly go downhill or something like that, who would need to have a transfer, that one we may put off because, like I said, our biggest problem has been trying to transfer the patient. But if we know that we have beds available and that we have enough supplies, we’re continuing to do those elective procedures for our patients.

WACOAN: You talked about transferring patients. Do you mean transferring within your facility or to larger facilities elsewhere?

Wuenschel: It’s transferring them to one of the tertiary facilities in the larger areas like Temple [or] Waco. For Dallas and Austin, we’ve had to call all over and had difficulties with that.

WACOAN: If a patient is in the hospital with COVID, what are your policies on visitors?

Wuenschel: It kind of depends on where they are in life. If it’s toward the end of life, we would, again, have them have on appropriate PPE [personal protective equipment]. But again, we need to weigh the risks and benefits because if you have COVID and the family member that’s coming to visit you does not, we don’t want them to get ill either.

WACOAN: Have you noticed a drop in people with other issues coming to the hospital, especially older folks? People who might normally come in for something and might be a little wary of visiting the hospital right now?

Wuenschel: I’ve had some patients who try to put off their preventative health at times, but we’ve been trying to reach out to those patients and explain to them all the things that we’re doing to help them.

WACOAN: Once COVID is under control, do you see any permanent changes in the way that your facilities operate?

Wuenschel: I don’t really see telehealth going away. I think lots of people have liked that. It does help us keep track of our patients whenever they’re not able to come in as easily. So I think that’s going to stay. I think even some of the technology of text messaging and things like that are going to stay.

WACOAN: Do you have a bunch of folks working remotely, or is everybody still coming to the office?

Wuenschel: We still have most people come into the office. But prior to this we did have some people working remotely anyway, doing coding and billing and things like that.

WACOAN: Have you had to hire more people in the last 10 or 11 months?

Wuenschel: We have. We have hired a COVID team, essentially, people who help with the screening, people who do the callbacks, people who do the lab, all of that.

WACOAN: Have you had any struggles in filling positions and getting enough people to work for you?

Wuenschel: No. I think we’ve had an influx of applications, so it’s been good to get the right people on and have enough people.

WACOAN: Did I read that you’re also the county health director? Is that correct?

Wuenschel: The local health authority. Yes.

WACOAN: What has been your role there in dealing with COVID?

Wuenschel: I worked with the school districts within our county on how to help them safely return students to school, keeping them on quarantine when appropriate, and helping them with the testing, making sure that we get [students] tested. I helped Gatesville ISD write their policy about returning to school and returning to work. And the other thing is working with the county judges about in-person trials and jury trials and things like that.

WACOAN: Does Coryell County or Gatesville have a mask policy?

Wuenschel: Yes. They do have a mask mandate. It’s recommended.

WACOAN: As you have been out and about in your community, how has compliance been?

Wuenschel: I would say there’s not a lot of compliance. I have seen it improve over the last few weeks. Of course, just like with anything new or any kind of change that we have, people don’t start to work with it until it’s actually affected them. And we’ve had a significant increase in numbers here. And so I’ve seen more and more people whenever I do go out and about wearing masks, but it’s still a difficult thing. Masks are not fun.

WACOAN: No, they’re not. You said there’s not been a whole lot of compliance. Is that a rural, smaller town kind of issue?

Wuenschel: I think a lot of it has to do with knowing somebody that’s affected, when it hasn’t hit the community hard. But like I said, over the last few weeks, it has hit our community. I’ve seen some increase in masks. We all have fatigue about it. I saw everybody in March and April wearing masks and making sure we’re social distancing. But then you get fatigued, and you get tired, and you don’t want to do it anymore. And then you don’t see it in your community. You don’t see it affecting your community: ‘Oh, it just happened over there. New York, you know, that’s up there, those Yankees up there.’ But then whenever it finally comes down and is starting to affect the community, that’s when we start to see some improvement [in mask-wearing]. But I think, unfortunately, all of us start to think that way. You know, if it’s not happening on our soil, near us, and it’s been going on for this long, it just makes that difficult.

WACOAN: Where is Coryell County in the list of getting vaccines?

Wuenschel: We did get our first batch of vaccines. We got 300 for the clinic and 200 for the hospital. We’ve given all of them out, and we’re just waiting on the state to give us more. We have made some plans, depending on the amounts that we get. If we get a significant amount, like a thousand, we plan to do a drive-through vaccine clinic, and we have it all planned. And if we get a smaller amount, we have lists of patients to call. Again, we’ll use that technology, that QliqSOFT technology, to send the text message out to try to get as many arms vaccinated as we can.

When the CDC changed their guidelines on testing between day five and seven and then being out for 10 days if you hadn’t tested positive — we had actually already [changed our procedure] based on things that we had read about the declining positivity rate between day five and seven. We had already started utilizing that at the beginning of the school year to get the students back to school faster. And similar to the testing, we were already testing our employees once a week, and then twice a week at the nursing home. In California they just started testing their employees. And we were like, ‘Well, we’ve already been testing our employees basically this whole time.’

We are very unique because we have everything attached. We have that nursing home attached to us. And so it’s been very, very important to us to keep [COVID] out of our nursing home. Whereas other nursing homes are separated, but we are attached to the hospital, attached to the clinic, the entire building is attached, and so trying to make sure it doesn’t go across the campus has been a very important thing to us.

WACOAN: What kind of rates have you seen at the school district in Gatesville?

Wuenschel: At one point, essentially, when basketball started up, it was that indoor type of sport [and rates began to rise]. And that may have had to do with the type of mask that they were wearing. We actually switched up their masking because they were wearing the gaiters. And when they changed that, I did see the numbers start to decrease. They were very strict, and they were doing really well.

And then it may have been as everything went indoors, and it became colder, and it wasn’t football season anymore, which we can see across the entire country, that people started slacking off around October, Halloween, and we started seeing numbers increase drastically because, again, we’re fatigued. We’re tired of it. But they’ve been very welcoming to any types of things that we’ve given to them to try to improve that because it’s very important to our superintendent that we continue in-person school, because of course, we’ve seen that those students that are doing online schooling are having more difficulties for sure.

Dr. Umad Ahmad
Baylor Scott & White – Hillcrest
“Health care heroes are the leaders, just like our military people. That love they get from the community helps them to get recharged.”

Dr. Umad Ahmad is the interim chief medical office at Baylor Scott & White – Hillcrest. He was previously chief medical officer at AdventHealth Central Texas in Killeen and president of medical staff and chief medical director of cardiology at AdventHealth before that. He holds degrees from Allama Iqbal Medical College, in Lahore, Punjab, Pakistan, and the University of Texas.

WACOAN: How long have you been at Hillcrest?

Ahmad: I have celebrated my eighth week here.

WACOAN: What kind of medicine do you practice?

Ahmad: By profession, I’m a cardiologist, and I am still a practicing cardiologist.

WACOAN: Tell me about jumping into a new place in the middle of a pandemic. How did that go?

Ahmad: I don’t know if you’re aware of the circumstances, but my previous chief medical officer had to take a leave of absence here in this facility because of family reasons. I’ve looked up to him through many, many years. Dr. Jim Morrison is phenomenal, very loved and liked by everybody here. Very difficult to fill his shoes, honestly. But [I was chosen] internally because I was experienced, was chief medical officer in the community, who knew the Central Texas area. I helped start the cardiology program in the Waco market a year and a half ago. So I knew this market a little bit. And I was serving a similar market like McLennan County, in west Bell County and Coryell County. So the market structure is the same. They have the same CDC [guidelines]. They have a young population with Fort Hood. And they also have independent community providers and a mixture of employed physicians. It’s a similar set of circumstances. And when they offered me the position, it was an honor for me to be part of this facility in this community. That’s how I got into this particular job.

WACOAN: So how has it been for you so far? Have you been overwhelmed since you started in November?

Ahmad: I’ll be honest with you. It’s nothing for me because I have a great team around me who were running the program while Dr. Morrison was struggling with his family challenges at the time. I have a great group of leaders in the health care system, who are experts in their fields, whether that is the nursing field, operational field or clinical field. I’m just happy to represent them. I’m just the person who is representing them, and they are making my life so much easier. The poor frontline team members are the ones who are struggling. And it hasn’t been difficult for me. I’ve been embraced and loved by people who allowed me to be part of this community.

WACOAN: What have been the biggest challenges that Hillcrest has faced since you’ve been here?

Ahmad: It’s the burnout. It’s the staff burnout which has been the biggest challenge for all of us. See, they wake up every day. They are committed, and they are excited to take care of the patients. But my staff members who are taking care of the patients, either in ER or ICU, they see the sick people. They see their [patients] losing their lives and going back to the creator, our God, and that takes an emotional trauma. That’s one factor.

Number two factor is that they actually jump in, in spite of our hospital being overwhelmed, they have canceled their vacations and time off to be available for our sickest patients. When initially COVID happened and we wanted our frontline team members to put their lives at risk, we were astonished and shocked to see that they were signing up to be the frontline people, to be the first people to jump in while we did not know how deadly this disease was or how we can keep ourselves safe. Today, almost 10 months down, we know the disease much better.

So fatigue factor, emotional and also physical fatigue, I think, is taking the biggest toll on my colleagues.

WACOAN: You said Hillcrest is overwhelmed. Is that overwhelmed by the number of patients, lack of space, lack of supplies, or something else?

Ahmad: Fortunately they have the supplies, so supplies is not an issue. Space issues, not inundating them — that’s the challenge. That is my role, my role and my operational leaders’ role. And we have different tiers of space openings and processes in place. When something goes beyond a certain number, we automatically open a space and provide the staff.

The staff are overwhelmed with the emotional trauma they are going through with the sickness of the [patients]. When they lose somebody, my staff equally gets traumatized. And when they lose [patients] they are holding the hands of the sick people when they are dying. It’s not only the family members who get traumatized. We just cover our emotions. We are also emotionally involved in their care. It’s a trauma to [medical staff]. And that’s my fear. They are working day in, day out. I’m more worried about their emotional tiredness than physical tiredness.

WACOAN: As your frontline people become emotionally worn out, what can they do to recharge and get up and face the next day?

Ahmad: Certainly we as a system — all these systems, fortunately, are large enough that we internally are analyzing and putting teams in place to provide them the spiritual support, some kind of relief inside. They have mentors. I’m assigned to some colleagues of mine who are providers and nurses. And I check on them.

Also community. The community has done a great job, and that’s another support. When we hear from the community about team members and leaders, that they are health care heroes, that boosts them. Because I’m new to the Waco market, I can speak for the Killeen market, that the community came in and got together outside the hospital in the cars and honked [in support of health care workers]. I know it was done here too. So those kinds of things, including the media and social media [support].

And when we are in restaurants or somewhere it’s important that we show that health care heroes are the leaders, just like our military people. They get overwhelmed, and they get recharged. That love they get from the community helps them to get recharged.

WACOAN: The state issued a mandate regarding elective surgery. How is Hillcrest handling elective surgeries?

Ahmad: We follow the state. We are strictly following the governor’s orders. Our entire health care system, 50-plus hospitals, we passed our 15 percent mark way back when, and we held back on our elective surgeries, which need an overnight stay or which can deplete our resources. Right now we are pretty much not doing any elective surgeries unless they are lifesaving, like cancer, or anything which can bring them harm. So they have to define that very clearly, and only then is there an approval process. Only then can they get onto that list of getting the surgery done. So right now we are postponing a lot of elective surgeries.

WACOAN: Let’s say somebody comes into the emergency room with a heart issue or a broken leg, and then somebody is with that person to assist them. What’s the protocol on COVID testing for incoming patients and visitors?

Ahmad: There was a time that we practically closed the visitation, but now we have understood how to keep the visitor safe. So right now if somebody walks in, in this example for an emergency, and there’s a loved one needed, we give the [visitor] a mask. We screen them also and get them in and keep them safe while we are taking care of their loved ones. Everybody’s wearing masks. We are hand sanitizing. We are keeping them safe. And they are getting all the necessary testing.

If they need (in this example), if they need knee surgery because that’s the reason they fell down, then we can’t afford for them to fall down again. That’s an urgent situation. That’s something which will harm them. So we proceed with that surgery.

Or open heart. We have two people who are having angina or chest pain or a heart attack, and they are going for open heart surgery tomorrow. I know them. Both of them are under 50 years of age, ironically. We are providing all the necessary care which is needed to make sure that our community members can live a good quality of life and a safe quality of life.

WACOAN: If a COVID patient is at Hillcrest, what’s the policy on visitors?

Ahmad: To the best of my knowledge, we are restricting the visitation over there, to keep safe the community members, but we do provide other virtual means of getting them connected with family members.

And if, God forbid, there are end-of-life decisions being made, then we bring in the family members. Then we make exceptions. We give them the masks, the face shields, and bring them in and keep them safe and let them bond with each other. There are times we make exceptions, yes.

WACOAN: Also with COVID patients, is the policy to limit it to one patient, one nurse? And do you try to limit the number of people in the rooms, including doctors, nurses, housekeeping folks?

Ahmad: So let me give you an answer to the journey that we took. That will give you a little more clarity.

In March and April, when we started, we literally restricted any kind of movement in and out of the doors. We did not know how badly this disease spread and how we could protect people. So we restricted.

Fast forward. Now we have all kinds of specialty equipment. We have identified the folks in every department and division who are less at risk for getting any harm and who can use the protective equipment, so they can go in and take care of the people, whether it’s a nurse, a phlebotomist. Even if they need physical therapy, we are able to provide the people who can go in and take care of those patients so they can get the same level of care like non-COVID patients.

Now let me give you another sidebar, from the engineering point of view. We have not only the HEPA filters, but we also have what we call negative pressure [ventilation]. We have made the air circulation in a way that it throws the air out from the COVID room so it doesn’t come into other areas. So for that we keep the doors closed. And you prepare the gear and whatever mask you put on outside [the room]. And when you come out, there’s a place where you can take off the gear, and so when you come out to the rest of the community, you don’t carry with you any kind of disease. Those protections are very clearly aligned there.

But we have gotten very comfortable that anybody can walk in and take care of these patients. And there is no provider restriction anymore. No cleaning person restriction. No phlebotomist restriction. No physical therapist restriction. We have gotten smarter internally that our employees who are immunocompromised, who are older, that they don’t go and put themselves at risk.

WACOAN: Do you think there will be any permanent changes in the way hospitals will operate after COVID?

Ahmad: I do, actually. It’s not only me — all the health care people, we believe it’s going to bring dynamic changes in the way we are practicing. I’ll give you a few examples of that.

One of the perfect examples is actually what you and me are doing, the teleconferences, telemedicine. I’m going to go to the clinical world first. We used to host a lot of meetings between this doctor, that doctor. He had to leave his practice, spending an hour or 30 minutes in the traffic, come and meet, do the meetings. Now we learned how to do the virtual meetings, and they have been very successful, and we have become more efficient. That’s number one.

Same goes for telemedicine. Not only are telemedicine portals available during the daytime, where somebody, depending on their kind of job and their needs, if there’s a loved one who’s older, who they don’t want to leave alone, they can now sit at home, connect with a doctor, continue the care. That’s another change that’s happened.

The third major change is people have started understanding a little more how to be more efficient in using ER visits. We used to get an ingrown toenail, a little bit of bleeding in the nose. They were coming to the ER. That traffic I don’t think is going to come back to the ER for a while. Only sicker people are coming to ER, and ER utilization has actually become better because we are getting the right group of people visiting. So the waste of ER has gone down. And that allowed the sicker people to come in and get the right care they need.

And for COVID, we brought in masks. We hardly saw any exacerbation of flu this season. We didn’t see any major [increases] of flu pandemic. That just got wiped away with hand washing and with our masks. I don’t think social distancing is needed down the road. But that will not be a nationwide thing. That will be depending on the kind of business you run. They will encourage masks — I don’t know if they will force them upon you. But it will become an acceptable thing that you are wearing a mask, if you wish to, down the road, like during the flu season because you have kids at home or an older person at home, so that you don’t carry [sickness] back home.

These are multiple examples that I can think of which are going to bring changes in the health care world. And they are going to stay here for longer.

And I’ll give you a perfect example from my own personal life. My kids did not fall sick for the last eight months. I have young kids. They used to fall sick quite frequently. And they haven’t, knock on wood. We are pleasantly shocked, but it’s because we are using all those protective layers. And I’m going to continue implementing [precautions] as much as I can, especially during the winter season.

WACOAN: Is there anything else that I need to know?

Ahmad: I did mention the burnout factor. I do want to acknowledge my health care colleagues. I want to praise them. I wish there was some kind of way that I could tell them how much I appreciate their heart for them putting themselves at risk.

I also want to appreciate the city of Waco, the mayor and the judge and how they are doing weekly press conferences and are engaged in finding avenues in how they can make things happen for the health care community and keep the community safe. My hope is that this vaccination takes effect and pretty soon we are eradicating this COVID out of our lives.

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