• The Calm Before the Storm

    Philip S. Barie, MD, MBA, Master CCM, FIDSA, FACS

    Philip S. Barie, MD, MBA, Master CCM, FIDSA, FACS

    Professor of Surgery and Medicine (Public Health)

    Weill Cornell Medicine

    New York, NY

     

    March 23, 2020

    That’s what they’re saying: Governor Cuomo, Mayor DiBlasio, hospital leaders. Judging by the large crowds that congregated in city and state parks on a beautiful afternoon last Saturday, the message may not be getting across. Now they are reiterating forcefully.  Stay at home, in New York, New Jersey, Connecticut, Illinois, California, and now Massachusetts. For now. Even the U.S. Surgeon General has entered the fray. Take this seriously!

    Or does the fact that we are not yet overwhelmed medically mean we are succeeding in “flattening the curve?” We won’t know that for at least two weeks, but from this vantage point, it sure doesn’t seem so. Cases and deaths are increasing exponentially. Precise numbers are impossible because they change by the minute. And the crystal ball is cloudy.

    ‘Right now’, (www.epidemic-stats.com), there are 41,526 confirmed U. S. cases, with 501 deaths. Statewide, New York is reporting 20,875 cases, with 157 deaths. At least the mortality rate is plummeting in the U.S. (now 1.2%) and New York State (0.8%), but what will happen when (if?) we run out of ventilators?

    All New York State hospitals have been mandated to increase their numbers of beds by 50%. Here is the simple, stark reality we may face. We have 53,000 acute care beds, most in the New York City metropolitan area. Bed density is much lower upstate, especially outside the larger upstate cities such as Buffalo (Go BILLS!). The mandated increase will get us to 77,000. We are projected to need 110,000 beds when we peak. That is why the state has asked for doubled capacity. What will happen when we have to open the four temporary hospitals that are now planned for Manhattan, Westchester, and Long Island? All those new hospital beds and ventilators that have been promised may go there.  So may the retired practitioners whom the state has called to volunteer.

    How many patients are critically ill? Harder to tell, based on public information. The Governor said earlier today that about 600 patients are in ICUs In New York State. That would be about 2.9%. Suffolk County (eastern Long Island) just reported 1,475 cases, of whom 38 are in ICUs (2.6%). But if they are concentrated in the larger centers, those percentages may seem cold comfort to weary, embattled pratitioners.

    Call last Thursday was weird; this takes getting used to. Rounds in N95 masks (hard to wear for more than an hour or two at a time). Only two operations, both take-backs of ICU disasters. Didn’t have to use our shiny new COVID-designated operating room, but it sure is comforting to know we have one. Now if we could only get one for trauma…

    I spent the rest of the night either as a “resuscitationist” or coordinating the movement of critically ill patients for cohorting. You see, our ICU has now been designated as the non-COVID medical-surgical ICU for all comers. (That will last, I predict, only until the other COVID-designated ICUs, which is basically all of them, overflow). Staff are happy for now, morale is pretty good, because we might get some interesting cases (amongst other reasons). Reminds me of my youth before we became the beneficiaries of an infinite number of consultants bearing “recommendations.”

    Our two virus-positive patients were moved out, and we had a lot of admissions from just about every other ICU, as the MICU becomes COVID-central. The hospital tells us we have patients on ventilators numbering in the high-thirties. We have either fifteen spare ventilators…or 35. Even redoubled communications can be confusing.

    Shortages of PPE are not likely to improve soon. Our hospital system president, Steve Corwin [a cardiologist], said on national TV over the weekend that normally, we go through about 4,000 masks/day system-wide, but that now the number is 45,000!

    More soon. I’ll be in the unit starting Monday, right when this is supposed to peak. Prepare for takeoff. Protect your patients. Protect yourselves. Protect your families. Protect each other.