Stunning…
Philip S. Barie, MD, MBA, Master CCM, FIDSA, FACS
Professor of Surgery and Medicine (Public Health)
Weill Cornell Medicine
New York, NY
…in its virulence, its contagion, and its rapidly spreading pervasiveness.
Inspiring…
…from the strength, creativity, and innovation bordering on heroism of caregivers, especially our colleagues in critical care nursing and respiratory therapy.
Frustrating…
…because of looming shortages and the realization that, as bad as it already is, we are really only two days into this onslaught. The peak is maybe three weeks away.
This pandemic has worsened so rapidly and taxed resources so dramatically, and it’s only been two days since the dam broke Wednesday March 25 here in New York. The Epicenter. What we understand is to come stretches credulity to its limits. Unless you’re already living it. Colleagues in Atlanta, Detroit, Chicago, New Orleans, and Houston report that hospitals are filling rapidly with COVID-19 patients (as the disease has come to be called). Many if not most major U.S. cities are mere days behind us. You are likely to be living it soon. Take it as a last few precious moments to prepare.
There were so many important things planned to talk about in upcoming blog posts, but the rapidity of transformation has seemingly made them ancient history. The epidemiology doesn’t matter anymore-it’s everywhere. How to operate on COVID-19 patients (we aren’t doing much operating); how to transform your operating rooms into three-bed ICU cubicles (that should already be well underway)? Succinctly, my aims are to tell you where we are, and where we are headed.
The dam broke 48 hours ago, just as we emptied our unit completely into our one remaining non-COVID unit, which is now a med-surg all-comers ICU that is under our purview. The census is 11 patients, five of whom have burns. That’s it. We are being transformed into a several-hundred-bed (who knows how many ultimately) respiratory intensive care hospital. Non-COVID non-critical patients have been moved across the street to our orthopedic specialty hospital. We received nineteen new, ventilated COVID patients in less than 48 hours. We still have one negative-pressure room reserved for respiratory procedures (intubations, bronchoscopy (avoiding), tracheostomy (also avoiding). We’ll see how long we are permitted those luxuries.
The next phase will be filling the PACU, then the step-down units, then (at the Apocalypse) the operating rooms (three beds per). We are crash-training 300 non-critical care nurses (in two weeks) to function in the critical care setting. Our nurses, great teammates and heroes each, will likely disperse soon thereafter to supervise these new team members. Tomorrow we acute care surgeons are forming six teams to cover our responsibilities (three ICUs, trauma and emergency general surgery M-F, burns), with 12-h shifts around the clock, five days on/two off. Each team will have a random internal medicine attending, a fellow, one P.A., and a smattering of residents, hopefully ours).
As for the patients, some things to note. ECMO is so scarce as to be off the table. Haven’t had to “prone” anyone. They deteriorate quickly from a pulmonary standpoint, but their infiltrates (CXR) are patchy and not that impressive. They like PEEP a lot, as their lung compliance is not as bad as you might think, but > 15 cm H2O seems not to help. The cytokine storm is substantive, everyone is febrile and most require norepinephrine. White cell counts are all over the place. All “persons under investigation” (PUI) receive (rightly?) ceftriaxone and doxycycline for up to 48h until tested negative. There is a high incidence of pre-renal AKI. Despite reticence about fluids in ARDS, patients on high PEEP (> 10 cm H2O) need fluid to maintain preload. No one we have is deemed sick enough for antiviral therapy, so nothing to report yet there.
Supplies of PPE are adequate so long as we are careful and unselfish. We still have ventilators. Other shortages abound. Fentanyl. Propofol. Cisatracurium. Azithromycin. Blood supplies are dwindling as donors stay home. And really, we’ve been at this for just two days.
Around and about, staff are beginning to test positive. Morale remains high. The Javits Convention Center has opened as a 2,000-bed temporary hospital. The U.S.N.S. Comfort arrives Monday to be a 1,000-bed non-COVID inpatient facility. A nurse in the care of COVID patients in the Mount Sinai system has died of the disease.
Protect your patients, yourselves, your families, and each other. Stay well.