• Descent into Hell

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

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

    Professor of Surgery

    Professor of Public Health in Medicine

    Weill Cornell Medicine

    New York, NY

     

    Yea, though I walk through the valley of the shadow of death, I will fear no evil; for thou art with me; thy rod PPE and thy staff pizza deliveries, they comfort me.                                     

    Psalm 23 (with apologies to King James)

     

    New York City COVID-19 Cases               Confirmed                Deaths

    Apr 5 at 07:13 local time                           63,606                      2,624

    Apr 8 at 15:07 local time                           77,967                      4,111

    Apr 14 at 13:53 local time                       106,683                      7,349

     

    The statistics defy credulity and imagination. 106,000 afflicted in New York City, and more than 202,000 (10,800+ deaths) across New York State. About 10% have required hospitalization, and about 25% of those, the ICU (and a ventilator). Casualties (the word was chosen carefully) of this magnitude have not been seen ever before in peacetime. We’re been stretched to our limits medically, and in some locales, beyond.

    The politicos and the epidemiologists say the curve is “flattening” in New York State. I hope so, for all our sakes. From my perspective, its harder to tell; I still have three intensive care units (one that is makeshift [transformed from an ambulatory surgery recovery area]), full of 52 critically ill patients with COVID-19, collectively among the sickest patients I have ever cared for. As the number of new cases presenting directly to us decreases, we are taking patients in transfer from beleaguered smaller hospitals in our network, so we are always full with COVID-19, and will be for some time. There is no end in sight, no return to normalcy (in whatever form that may assume.)

    I’ve been in the ICU for most of the last two weeks, so I am coming to understand this disease. Even as we were learning about COVID-19 and managing individual patients, the similarities among patients were striking and it became challenging to keep track. Imagine making rounds on 20 critically ill patients every day, and at every bedside the situation is nearly identical. Upwards of 100 daily arterial blood gas determinations to account for, and that just one of many, many “moving parts” day-in and day-out. Renal function and hyper-coagulability require equal attentiveness. Thus, we had to change fundamentally what and how we communicate. We also had two other tasks to manage simultaneously. Knowing that we would be tasked to manage multiple units, perhaps in disparate locations and certainly with the assistance of practitioners reassigned from other clinical duties and unfamiliar with critical care, we had to adjust existing protocols and create new ones to support these unique, unstable patients. Of equal importance was supporting our teams, maintaining high reliability and morale lest we be faced with the certitude of failure.

    In a way it has been exhilarating, having skills and experience to respond effectively to a crisis of such magnitude. It has been refreshing to think deeply again about respiration physiology, on which I “cut my teeth,” and multiple organ dysfunction syndrome, to which I devoted my voyage of discovery. I thank my mentors every day. At my core I am a university professor as well as a surgeon, a clinician-scientist and a teacher. In the midst of this horror, we are providing skilled and compassionate care, teaching, learning, and answering questions. Importantly, keeping our teams cohesive and high functioning. The “rules” being somewhat relaxed and the “authorities” being somewhat distracted, it has been conducive to innovation and bold steps when necessary for the benefit of the patients.

    The patients and the circumstances continue to challenge us. The issues surrounding respiratory failure are now pretty well known. Limiting PEEP to 15 cm H2O has seemed wise; dynamic compliance is somewhat better than anticipated for most patients. There is no preferred mode of ventilation; we have enough ventilators but some delivered recently to us are not programmable for certain advanced modes, so we have to tailor mechanical ventilation not only to individual patient physiology but also to the type of ventilator in use. Prone positioning is applicable to some individual patients but not all, and then sometimes only transiently, and overall has been of limited utility.

    Acute kidney injury is likely multifactorial and especially nettlesome. Early pre-renal azotemia related to reticence to administer fluids to patients with respiratory failure, nephritis believed to be related to the high concentration of hACE2 receptors (to which the coronavirus spike proteins bind) expressed by the kidney, and pigment injury from viral myositis, rhabdomyolysis, and myoglobinuria (of which we have seen three cases thus far). The need for renal replacement is taxing resources, with machinery, dialysate fluid, and dialysis nurses (because of viral illness) all in short supply.

    A hyper-coagulable state is highly prevalent, manifested by hyper-fibrinogenemia (part of the acute-phase response) and D-dimer concentrations that usually exceed five-fold above the upper limit of normal. Overt manifestations include venous thrombosis, and it is surmised that pulmonary micro-thrombi may be contributing to ventilation-perfusion mismatching and impaired gas exchange. Arterial monitoring catheters are prone to clotting, as are venous dialysis catheters. All patients are now anti-coagulated fully to combat this problem. Spontaneous arterial thrombosis is fortunately rare.

    Finally, let me extend a few heartfelt words of thanks. To our faculty colleagues, who have pitched in immeasurably with crucial tasks such as maintaining close contact with families now that visitation is suspended. To colleagues and erstwhile residents, who have volunteered to help us provide patient care, contacted us to impart how the training they received as residents has helped then function now as impromptu intensivists, or just to provide expressions of encouragement. To our donors, whether providing ventilators, PPE, or the enormous quantity of takeout food that sustains us. And to the readers, for considering these words. Thank you all.