Full-time Professor Taking Shifts at Three Different Hospitals
The ratio of patients to clinicians is much higher during night shifts, and PAs are called on to do more.
Alicia Kelley, MPAS, PA‑C, Director of Didactic Education and Assistant Professor in the MCPHS School of Physician Assistant Studies, not only works a full-time teaching schedule, she also works as a PA in hospital/internal medicine. And when doing so, not only does she work in three different hospitals, but the hospitals themselves are each in an entirely different system. She works at Nashoba Valley Medical Center, in Ayer, Massachusetts—part of the Steward Health Care System. She works at Lahey Hospital & Medical Center in Burlington, part of Beth Israel Lahey Health. And she works at Newton-Wellesley Hospital in Newton, part of Mass General Brigham (formerly Partners). "I’m basically what you could call a moonlighter or a per diem person,” Professor Kelley says. “I fill holes and gaps in their schedule. The shifts can be during the day, the evening, or overnights. They can be weekday or weekend shifts.”
Kelley’s PA work ordinarily involves inpatient medical management which involves admitting patients to the hospital, and occasionally making rounds. She sees patients with a “wide variety of different types of conditions, from gastrointestinal, neurologic, cardiac, infectious, and more.” But her usual inpatient population started to look a lot different in March. "It became, wow, every single patient seems to be possible COVID, presumed COVID, or confirmed COVID.”
It was overwhelming. And the night and overnight shifts were particularly hard. The ratio of patients to clinicians is much higher during night shifts, and PAs are called on to do more. Kelley says her pager would go off incessantly, leaving her feeling like she was playing catch-up all shift long. And far worse, she was suddenly having to pronounce a great number of patients dead—she says that the amount of death the disease has wrought has been stunning. "I have had to pronounce people that I never met before.... I just happened to be cross-covering or I just happened to walk into my shift and then there's somebody who has deceased, very shortly before, and I end up giving the call. And so that's been really hard because I've had to talk to families that I didn't even have a chance to develop a relationship with...the family members were not allowed to come into the hospitals. So you have to call them over the phone to tell them about their loved ones passing away. And that just doesn't seem right.”
At first, she says, everyone was learning on the fly. It wasn’t even clear whether masks were useful: no one was sure if the disease was airborne, or droplet—the way it spread was unknown, making initial guidelines inconsistent. "It was stressful,” Professor Kelley says. “In medicine we're used to following recommendations by our experts and the evidence-based medicine based on studies. But here this is something brand new, and the tests weren't working. Nobody knew anything about the disease.”
But, she says, medical professionals are particularly suited and trained to adjust to chaos. They observed and learned, and the guidelines started coming. The hospitals she works at used new resources. They gave PAs more room to operate independently. At Newton-Wellesley, they brought in physicians who weren't normally hospital-based doctors. They converted a regular Med-Surg floor to become an additional ICU. Before the hospital got new ventilators, they utilized ones that were normally in the operating room, and they had a critical care doctor stationed on that floor the whole time.
The hospitals also brought in specialists like cardiologists and oncologists to help out with general work. Orthopedic PAs were transitioned to internal medicine to help. It was all hands-on deck. Nashoba Valley, because it's a small, 30-bed hospital with an even smaller ICU, decided to designate certain hospitals to be COVID hospitals. Kelley was impressed how the institutions were able to be nimble in the face of new challenges.
“I’m proud to work in Massachusetts and work for these fantastic institutions where they have such great leadership. And they execute so well...it felt like magic, like watching the creativity and the organization and the leadership and the way all three hospitals manage to just keep...responding daily to the new norm and new needs and new discoveries.” She says she’s proud to be a part of places that are so well led.
Professor Kelley adds that hospital administrators have gone out of their way to show her and her coworkers support and appreciation during the pandemic. But that doesn’t mean she feels like a hero. “I think medical workers kind of feel like soldiers anyway,” she says. “We have to run to the bedside when people start crashing. We have to alert family members when people are dying. We have to deal with end of life...you don't really feel like a hero, because that's the kind of stuff you signed up to do from the beginning.”
As for silver linings to it all, Professor Kelley says the sense of teamwork and compassion has increased noticeably. "I think that we are gentler with each other and more tolerant, more patient, more respectful, just realizing that everybody's kind of in the same boat” and that “we have each other.”
She has also been impressed by how research and approvals were able to move more quickly. She gave the example of blood clots. When doctors began to realize that great numbers of COVID patients were getting blood clots, the medical establishment quickly agreed on new guidelines and treatment protocols—something that would ordinarily take a long time. "It can be dangerous when you move too quickly,” Kelley says, but she wonders if the pandemic has shown that some guidelines and approvals can move more quickly when necessary. “This pandemic has also shown how versatile medical providers can be.”
The experiences Professor Kelley has had on the front lines have made her think broadly about healthcare and ask how we can improve it, and that’s a valuable exercise.