Crisis lessons from an ER doctor on the COVID front lines

Executive overview

Hospitals optimised for profit have no slack for surges. When COVID hit, emergency rooms across the US ran out of swabs, sedatives, and ventilators within weeks — not because the pandemic was unforeseeable, but because the financial incentives punish preparedness.

Dr. Ban Koo, an ER physician at Jefferson University Hospital in Philadelphia, describes what it took to keep functioning: sourcing clinical guidance via Twitter, 3D-printing test swabs in-house, and training volunteer teams to manually ventilate patients. The lesson applies well beyond medicine.

Efficiency without redundancy is a liability — crises expose what lean systems cannot absorb.

How the ER changed overnight

• Patient volumes dropped 40–50%; the ER fell eerily quiet in early March
• Colleagues appeared in full hazmat gear with no warning — the shift to crisis mode was immediate
• First shift back: intubated a suspected COVID patient before even getting oriented
• COVID cases plateaued relatively quickly; non-COVID emergencies (heart attacks, strokes) began returning
• Day-to-day variation made trend data more useful than any single data point

Sourcing real-time clinical knowledge

• No randomised control trials existed for a new disease; traditional journals were too slow
• Relied on Twitter, blogs, and podcasts from trusted ER colleagues in harder-hit cities
• The FOAM (Free Open Access in Medicine) community became a primary learning channel
• Electronic health records are designed for billing, not real-time clinical decision-making
• Siloed data systems prevented Philadelphia doctors from learning quickly from New York's larger caseloads

Improvising supply chains

• Partnered with an MIT team to design a bridge ventilator within one month
• Trained a volunteer corps to manually ventilate patients as a backup if ventilators ran out
• Repurposed the health design lab to 3D-print COVID nasal swabs in-house
• New York colleagues reported running out of sedation drugs for intubated patients
• Hospitals built for maximum efficiency had no buffer stock for surge conditions

Broken financial incentives

• Hospitals profit from elective procedures and specialty visits; they lose money on primary care and public health
• No payment model exists for preparedness — so hospitals did not prepare
• During the worst public health crisis in a century, some hospitals were closing and laying off staff
• A for-profit system with these incentives "cannot exist anymore"
• Countries that tested early, contained fast, and protected healthcare workers (Korea, Taiwan, New Zealand) had far fewer deaths
• A federal, unified national strategy is needed — piecemeal responses cannot contain a pandemic

The human cost of frontline work

• Feared infecting his family more than catching COVID himself; sometimes stayed in a hotel between shifts
• Decontamination protocol after every shift: strip scrubs, bag them, shower immediately on arriving home
• Seasonal allergy symptoms triggered constant anxiety about COVID infection
• A colleague and friend, an ER doctor in New York, died by suicide during this period; 300 ER physicians attended a Zoom memorial
• Two colleagues lost their mothers to COVID in the same week
• Going into the hospital felt like the most normal part of the day — purposeful work eased mental stress more than working from home

What needs to change

• Telemedicine is here to stay; the pandemic forced both patients and doctors to adopt it
• Broadband access is a prerequisite — vulnerable populations cannot access telehealth without it
• COVID disproportionately killed people of colour, those in unstable housing, prison populations, and factory workers
• Emergency rooms need physical redesign to prevent cross-infection during future surges
• Hospital payment must be restructured to reward public health and preparedness, not just procedures
• Thousands of deaths were preventable; the same mistakes must not be repeated in a second wave