A Hospital, a Hospitalist, and a Pandemic

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Dr. Grace Kwon describes her role at ChristianaCare’s Wilmington Hospital and explains how teamwork there has been so crucial during the pandemic

What exactly is a hospitalist? There is a good chance you may not know.

Dr. Grace Kwon certainly knows. She is a hospitalist at ChristianaCare’s Wilmington Hospital.

Kwon with her family, 5-year-old daughter, Olivia Kubacki, and her husband, David Kubacki.

In a recent phone interview, Kwon speaks with us about her role and the impact the COVID-19 pandemic has had on patients admitted to Wilmington Hospital.

“We have many acute illnesses that we are used to dealing with,” Kwon says. “We know what to expect [in those cases]. COVID-19 is completely different.

“We’ve seen a 20-something adult become critically ill, and an 80-something adult recover quickly.  I can’t give you an explanation for that.

“I don’t think anybody fully understands at this point. It’s interesting, fascinating, and at the same time, scary.”

Kwon began her post-baccalaureate pre-medical studies at Goucher College and received her Doctor of Medicine from the Albert Einstein College of Medicine, in Bronx, NY, where she graduated with research distinction.

Certified by the American Board of Internal Medicine, Kwon has co-authored publications and abstracts on various diseases and conditions. She also practiced medicine at two other hospitals in New York before moving to Delaware to continue practicing while starting a family.

This is our third article in “Front Lines of the Pandemic,” an Out & About series focusing on clinicians in our area. Here, Kwon talks informatively and passionately about the mystery and uncertainty that COVID-19 poses to medical professionals—and how it’s taken teamwork to create positive outcomes in Wilmington.

 

O&A: Can you explain to our readers what a hospitalist does? And what does that title mean to you personally?

Kwon: A hospitalist is an internal medicine physician who takes care of patients that require hospitalization. We don’t see patients outside of the hospital. So, the name is self-explanatory, but I don’t think everybody knows that we’re internal-medicine trained. At ChristianaCare, we’re also required to be board certified.

Hospital medicine is a fairly new field of practice for a physician. It was first described in The New England Journal of Medicine in 1996 so that isn’t so far back when you think of the history of medicine.

I’ve been a hospitalist since I graduated from my residency in 2008. I really got excited about taking care of hospitalized patients while I was in training in the Bronx. I found it was so gratifying to be able to take care of people when they’re very sick and vulnerable and then treat them until they are well enough to be discharged home.

During my career, I have seen hospital medicine evolve such that nearly every medical patient is now being cared for by a hospitalist. We really have become integral to the care of the hospitalized patient as well as to the system at large. I’m very proud to be a hospitalist.

 

O&A: Would it be fair to say that in our current state—a pandemic—emergency doctors would be the frontlines, and a hospitalist would be the person who looks after those patients immediately after ER and takes care of them until they’re discharged?

Kwon: Yes, absolutely. And you bring up a great point: The majority of our patients are going through the emergency department where there is a triage process.  Some patients won’t need to be hospitalized. They can be treated then safely discharged home.

Some patients will need to be hospitalized for a particular reason. The emergency department will then call us to discuss further and we will admit them to the medical floor and then take care of them until it is time for discharge.

Patients who are critically ill will require a higher level of care in the Intensive Care Unit (ICU).

For our patients who are sick with COVID-19 and require hospitalization, we hope that they can be admitted to our medical floor. But some patients will come in critically ill and require a ventilator. We don’t manage that on a regular medical floor where our hospitalists work. We rely on our intensive care colleagues to stabilize these patients, hopefully wean them off the ventilator, and then transfer their care to us later in the hospitalization to continue the recovery process.

 

O&A: When patients are discharged, are you communicating with them at all or are they just communicating with their regular physician at that point?

Kwon: The patients will return to their primary care physicians in the community after discharge. Or, if they don’t have one—which a fair number of our patients here at Wilmington Hospital don’t—we have the opportunity to link them with one of our outpatient practices in the community.

 

O&A: The recovery process. What does that entail for you as a hospitalist? Particularly now with COVID patients, what’s your part of that process?

Kwon: We have created specialized COVID-19 units at both Wilmington and Christiana Hospitals.

Outside of the ICU, we have multiple dedicated units for our COVID-19 patients. What that means is we’ve got actual hospitalists within our larger group, including myself, who are working in these units, and taking care of these patients, and keeping up to date with all the different treatment guidelines.

COVID-19 has only been with us for a few months, and because of that, the treatment we’re giving today is different from the treatment we were giving three months ago. Because it’s so new, we don’t have enough data to know that a certain medication is going to be effective or that you’ll recover fully from the virus.

But we’re working very closely with a comprehensive care team on the unit which includes caregivers from multiple disciplines. This includes our nurses and patient care technicians. We have respiratory therapists who are essential because many of our patients are respiratory-compromised. We’re working closely with our physical and occupational therapists. We have pharmacists and the expertise of our Infectious Disease specialists.  We also have case managers and social workers helping to develop safe discharge plans for our patients.

We have virtual rounds every day to discuss each patient and make sure that we get input from every member on the care team before we move forward with a plan for treatment and eventual discharge.

Even with maximal medical therapy, we are seeing some patients recover quickly whereas other patients require additional time. Again, we don’t have any explanation for why this variation occurs.

 

O&A: Are there any particular cases or experiences over the last two months that stand out to you as either a learning experience or something emotional that has changed the way you view your job?

Kwon: I had one [patient] recently ask me, “Doctor, am I going to recover completely to the point where I can resume my former level of activity?”

And he was just talking about, “Will I be able to take long walks around my neighborhood?”

This is a gentleman who had already been in the hospital for close to a month; he had already been critically ill in the ICU and received all the available COVID-19 treatments. We were working to stabilize him further so he could go home. He was fine while lying in his bed, but within seconds of standing up to take a few steps, he would become very short of breath and require a significant amount of supplemental oxygen.

This question struck me deeply. Typically, we have definitive answers for our patients and we have a degree of certainty about what their prognosis and recovery will be. For example, if you come in with an uncomplicated bacterial pneumonia, I can pretty confidently tell you, “You’re going to get better with antibiotics; I expect that you are going to fully recover; and you’re going to get back to your baseline level of activity.”

But for this patient, I had to be honest with him. I said, “I don’t really know. We don’t know, because we don’t have the data or experience to say you will.”

That creates an uncomfortable level of uncertainty, to say the least. But that uncertainty also creates an opportunity to learn more. But to learn more, we need time and we need more patients to study and analyze, to get to those answers with a greater degree of certainty.

 

O&A: When there’s uncertainty involved, there’s always more risk. When we don’t have a clear view of the facts, it’s really easy to let our imaginations or our fears draw between the points that we do know, right? What advice would you give to people who might have fears that may seem to be based on something other than the facts?

Kwon: I’m sure there are people who don’t believe this could be a serious illness. And while it’s true that some people with COVID-19 will just have “flu like symptoms”, there are certainly others who will require hospitalization or become critically ill, require a ventilator, and may or may not recover. For those of you who are skeptical, COVID-19 is real—it is serious, unpredictable, and not yet well understood.

We owe it to each other to be as safe as we can. With states reopening, we need to remain cautious and responsible.  I’m in full support of people getting out of their houses and starting to live life but we have to be safe. Continue to socially distance. Continue to wear a mask. Continue to protect our vulnerable populations. Wash or sanitize your hands and do it often.

 

O&A: You talked about the comparisons to the flu. How is COVID different from the flu based on your observations over the last couple months?

Kwon: Many of our patients who are infected with COVID-19 experience an intense inflammatory response that the body develops due to the presence of the virus-the so called “cytokine storm.” It’s wreaking havoc on your respiratory system. Sometimes it’s attacking your kidneys; sometimes it’s attacking your brain, heart, or other parts of your body.

We have blood tests that serve as markers of inflammation and for the most part, there has been a correlation between high levels and severity of illness. And as its name suggests, the “storm” can rage uncontrollably. We have seen patients who initially require minimal amounts of oxygen and within 24 hours, the inflammation has rapidly progressed to the point where they’re requiring very high levels of oxygen. In some patients, the inflammation has progressed to the point in which they need to be intubated.

We’re also learning that this inflammation can increase your risk for developing a blood clot in your venous or arterial systems. So we’re seeing people with significant clots in their pulmonary arteries or in the veins of their legs. We are seeing strokes as well.

Interestingly, the inflammatory response appears to vary. We are seeing it escalate in younger folks as well as the elderly, without any reasonable predictability.

 

O&A: Things being so unpredictable has to create a lot of stress. How has the staff at Wilmington Hospital adapted to the stress?

Kwon: It definitely has created a lot of stress on a personal and a system-wide level. [ChristianaCare] had things in place before COVID-19 happened, that were out there to help caregivers decompress and deal with high-stress situations. We have a dedicated Center for WorkLife Wellbeing that has been in operation for a few years that focuses, as its name implies, on the well-being of all our employees. So they’ve been a wonderful resource.

 

O&A: If you don’t mind me asking, what do you feel has helped you personally? What is it that helped you get through [these past three months]?

Kwon: I get emotional thinking about it because this journey has been so intense—unlike anything in 13 years of medicine I’ve ever experienced [voice breaking]. What has really gotten me through this is my family. I have a wonderful husband, a beautiful five-year-old daughter and in-laws who live locally—my parents and other family are not close by, but everyone has been so supportive, helping to keep me grounded and sane.

The team at Wilmington Hospital has been my other pillar of strength. It’s one of those places where you’ll be walking down the hall and everyone is saying “Hi,” to each other. There was a strong sense of community and a family type feeling here, pre-COVID 19. What’s happened since the pandemic began is that we’ve come together in a tremendously unified way and become so strong.  There is a powerful feeling among us that we are in this together, a feeling that reinforces our organization’s mission: “We serve together.” It has truly been inspirational.

We always worked well as a team but recently, the level of cohesion, the way we are communicating with each other, the level of personal commitment to give above and beyond—not just for our patients, but for each other—is something I have not seen or experienced before.

It’s been really extraordinary and it moves me to talk about it because [voice breaks] as proud as I am to be a hospitalist, I am even prouder to be a part of this incredible team.

 

O&A: Wow.

Kwon: If you could walk around with me to see what I mean, it’s palpable. I’m just extremely grateful to be at ChristianaCare and at Wilmington Hospital with a group of people that are so supportive of each other despite the unique challenges that COVID-19 has presented to us.

I think all of us have grappled with fear as the pandemic has unfolded. I remember my first day of rounding on the COVID-19 unit. It was March 14. I was the first hospitalist at Wilmington Hospital to take care of a suspected COVID-19 patient.

You can imagine the anxiety that I felt the night before. I couldn’t sleep because I was worried. I was thinking, “Am I going to be wearing protective gear properly? Will I be taking it off correctly? Will I be safe? Will my family be safe?”

The very first person I saw that day had a positive test result several days later. Needless to say, there was a tremendous amount of anxiety and fear in those early days.

Fast forward several months later to an incredible experience I had when we were able to call a “Code Blossom” for a patient of mine. A Code Blossom is a celebration of a patient’s recovery from COVID-19 and their discharge from the hospital. It’s called overhead and staff members come to the lobby so we can clap and cheer as the patient leaves the hospital.

It’s hard to put into words the overwhelming joy I felt as my patient was wheeled from the elevator to the entrance of the hospital.  Her tears of gratitude were met with my own of happiness and relief as I reflected that this is one of many victories we have won in this war on COVID-19.

So, what do you think? Please comment below.