ICU Training for a Pandemic: Fourth-Year Students and President Step Up

When the COVID-19 pandemic prevented fourth-year College of Medicine students at Northeast Ohio Medical University from completing their hospital rotations, decisive action needed to be taken. In a matter of months, these students were going to be taking their positions as newly minted resident physicians at hospitals near and far.

So, NEOMED faculty rallied to design new courses. And 22 students signed on for one that couldn’t be more timely: “Intensive Care Medicine and ICU Resources in Pandemics,” taught by the University’s president, John T. Langell, M.D., Ph.D., M.P.H., M.B.A.

“We’re using COVID-19 as a launching point to teach students intensive care principles around septic shock and multi-system organ failure,” said Dr. Langell in a recent interview. As the students learn about the pathophysiology of the SARS-CoV-2 virus, they also talk about the high-pressure situations that occur in an ICU, particularly in a pandemic.

What would happen if there weren’t enough ventilators, and not all patients could be treated?

As physicians, is there a moral and ethical imperative to keep going to work, no matter what?

Home Base: The Intensive Care Unit

Never before have these students had a course where they could watch in real time as their curriculum – a public health crisis without precedent in the United States – unfurled across the country.

“We have a few students completing the class remotely from New York City, and their updates on the pandemic [are] truly eye-opening,” said student Miah Brawley in an email.

Brawley learned from one of these classmates that a New York City residency program for which she had interviewed had experienced its first resident death. “Stories like this remind me that even though I feel like an invincible 24-year-old doctor, this virus can affect anyone and we all need to be careful and alert,” she wrote.

The COVID-19 virus typically leads to ARDS (acute respiratory distress syndrome), which often then spirals into sepsis, shock and organ failure. Because the sickest patients will be seen in the ICU, the course focuses on best practices for treating them there. The territory is familiar to Dr. Langell from his work as a surgeon (including in the Department of Anesthesia and Critical Care at MD Anderson Cancer Center at the University of Texas) and as an U.S. Air Force veteran who led four separate Air Force Reserve medical facilities.

Present for some of the remote teaching sessions is Dr. Langell’s wife, Sara Whittingham, M.D., an anesthesiologist and former assistant professor of anesthesiology who is slated to start a new job at Cleveland Clinic in July. Like Dr. Langell, Dr. Whittingham can speak to the students from her own experience working with critically ill patients in the operating room and in the deployed military setting.

Student Rob Link said in an email, “Dr. Langell gives us great insight into the coordination of health care facilities, supply chains and resource management, as well as education on screening, prophylaxis, triage and treatment of such patients.”

Personalized training

Each student has been required to make patient presentations, based on a situation provided by Dr. Langell. For each case, Dr. Langell looked up the actual residency into which the student has matched, then wrote a scenario for a patient having a medical crisis that the student needed to solve. For example, one scenario might read, “You’re starting your internal medicine residency at Memorial Hospital and your program director, Dr. Healwell, has assigned you to the medical ICU. Your patient is a 39-year-old female with SARS-CoV-2 who is spiraling into septic shock.”

Learning from each other

As a core part of the curriculum, the students read from The ICU Book and the latest medical literature, presented by Dr. Langell.

Students have also learned by making presentations to each other on risk factors, prevention and treatment. Link said, “From virtual patient rounds to case presentations on common and rare medical complications encountered in the ICU, we are consistently dared to build off the ideas of others and collaborate as a team.”

Class discussions have been lively, even heated, when ethical situations have been the topic, said Dr. Langell. As the students are well aware, ventilators are in short supply and so are beds, in many hospitals.

“When do we tell a patient, ‘We can’t treat you, because you’re probably not going to survive?’ he asked rhetorically. If a provider is immunocompromised, what is their ethical obligation to serve?

The class discussions about ethics have been especially meaningful, said Brawley, writing, “This course has brought into focus many questions and fears I have about starting my medical career during this pandemic.”

Preparing for a surge

In addition to their curriculum, students have tackled a project with a special immediacy: Developing a contingency plan for a potential surge of COVID-19 cases in Northeast Ohio.

The plan is for a facility where recovering adult COVID-19 patients who are stable but not yet ready to be sent home can be monitored and provided medical care. In case of a surge of critical patients, such a facility would free up bed space in hospitals for those with the most acute need.

Dr. Langell and the students have been collaborating with the Northeast Central Ohio (NECO) Surge Team – representing hospitals in 13 counties that are collaborating to increase inpatient capacity – and directly with Kent State University’s president, Todd Diacon, and Kent State’s nursing and allied health programs; the Ohio National Guard; the Army Corps of Engineers; Akron Children’s Hospital (led by John Crow, M.D., the associate chief medical director of ACH); Summa Health; Cleveland Clinic Akron General; Aultman Hospital and Mercy Hospital; and NEOMED’s Colleges of Medicine and Pharmacy.

Cyril Harfouche, who was commissioned as an Ensign in the U.S. Navy Medical Corps during medical school through the Health Professions Scholarship Program, stepped up to take the student lead on developing the contingency plan.

“I wanted to be involved in fighting this pandemic and serving our community, and leadership skills I have gained during my training and experience as a naval officer allowed me to feel comfortable stepping up for this role,” he wrote.

Dr. Langell deployed to the Middle East during an active campaign in 2004, providing care in the combat theater. For 12 of his 24 years in U.S. military service, he was commander of a military unit, which taught him valuable lessons about being able to deliver quality care in austere conditions like war zones, he said. To get the students started, Dr. Langell provided a template and published resources about alternate care facilities. They went on from there.

Of course, the best outcome would be if the COVID-19 outbreak in Northeast Ohio could be contained enough that the extra hospital would not be needed. But if a surge called for the facility to be assembled, who would be asked to serve? That answer hasn’t been determined.

With his students nearing the front lines of health care, Dr. Langell wants to prepare them – but still protect them from harm.