Hot off the press, a new paper published in JAMA Network Open looks at how clinicians working in critical care units or those involved in institutional planning responded to limited resources early in the covid-19 pandemic. In general, the idea of limited resources in United States hospital settings is by itself a highly unusual situation.

In this study, 61 clinicians from University of Washington and other institutions around the country were interviewed. Clinicians included intensivists (i.e. physicians working in intensive care units), kidney specialists, triage team members, trainees, palliative care specialists, nurse care coordinators, and others. Using semi-structured guides, clinicians were interviewed, and later the interviews were transcribed and coded using software developed specifically for this kind of qualitative research in an effort to discover any common themes that emerged across the interviews. 

Participants were on average 46 years of age, primarily female, and identified as White. Most (around three-quarters) of the interview participants were attending physicians. 

Themes that emerged included concerns regarding planning for crisis capacity, adapting to limited resources, and adjusting to unprecedented barriers to delivering care for covid-19 patients. 

One interesting common concern that emerged was the use of systematic approaches to allocations of limited resources. As we reported early in the pandemic, and as we are currently hearing from U.S. states in the Midwest and Pacific Northwest, when intensive care units become overwhelmed they are at risk of eventually running out of mechanical ventilators. In order to not burden frontline clinicians working in these critical care areas, systematic approaches were instituted so that the manner in which resources would be allocated in times of limited supply would be clear. Pre-determined institutional policies were in place so that seemingly impossible decisions regarding rationing would not need to be made at the bedside. 

Clinicians also discussed the role of moral distress in making these decisions during the pandemic. Other causes of uncertainty and stress included limited time with patients and families in-person, as well as the lack of scientific evidence early in the pandemic regarding the management of critically ill covid-19 patients. 

This unique paper provides a glance into the minds of clinicians who were either on the frontlines of covid-19 outbreaks or involved in institutional planning. Whether these stressors remain is unknown; we know now much more than we did, though pandemic fatigue may also be more prominent now than initially. Nevertheless, the weight of decision fatigue, moral distress, navigating patient and family communications, and challenges around taking care of sick covid-19 patients will likely remain for months to come.

Now that the Americans have cast their votes in the presidential election, will there be a greater appetite for a bipartisan coronavirus relief package? Earlier in the pandemic, the CARES Act passed through United States Congress, but as the national emergency has extended into the fall, no new bills have been seriously considered with the election looming.

Now, with record-breaking days this week in which new coronavirus cases in the United States topped more than 100,000 per day for the first time, and with hospitalizations on the rise placing greater strains on the healthcare system, it is evident that new legislative action will be needed. The partisan tensions that have precluded progress in recent months must now be cast aside.

While Senate Majority Leader Mitch McConnell had previously said that coronavirus relief would not likely happen until the new year, he has recently changed his tone, saying he hopes that a new bill can be passed by the end of this year during Congress's lame duck session, calling it "job one" along with funding the government past the December 11^th deadline. 

The stock market gains heading into Election Day reflected the optimism that the election would resolve Congress's stalemate over coronavirus relief. Indeed, while it appears as though Republicans may retain control of the Senate, with two Senate races apparently headed to runoffs, the uncertainty over the final coalition may give Congress added incentive to act sooner rather than later. With the Senate returning from recess on Monday, November 9th, we will see soon to what extent good faith negotiations are on the horizon and what the lawmaker's priorities will be.