• MAY 17, 2020

    A Gimmer of Hope

    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 Medciine

    Weill Cornell Medicine

     

    May 12, 2020

    A week ago, this essay would have been titled Darkest Before the Dawn, or words to that effect, but things have gotten better. A little. Two weeks ago we had responsibility for nearly 50 COVID-19 patients in three units (one temporary) in two buildings, one across the street, all on ventilators. As the new critical cases dwindle, we have been decommissioning the temporary ICUs, importantly including the operating rooms and post-anesthesia care units that were pressed into service and full of critically ill patients at the height of the pandemic. Now we are managing 18 patients, six of whom are still really sick. But the definition of “sick” has changed. Arterial blood gases that we would have seldom tolerated before became commonplace, even celebrated. I have given more inhaled nitric oxide and epoprostanol, and turned more patients prone in the last six weeks than before in my entire career. Therapeutic anticoagulation was given as prophylaxis because of the ferocious hyper-coagulable state. More than 100 tracheostomies have been performed.

    Collectively, the 94 patients we have cared for with COVID-19 over the past six weeks are the sickest we have ever encountered, yet remarkable in their “sameness”.  We understand them well now, and we continue to learn. We have made several novel observations, and the process of contributing to the literature is well underway. Along the way we changed how we deployed, how and what we communicated, and integrated many practitioners inexperienced in critical care to participate as providers, including more than 400 registered nurses crash-trained by our nursing colleagues in a mere two weeks.

    We have admitted just one truly new patient in the last two weeks, a kidney transplant recipient who developed severe COVID-19 with acute kidney injury, manifesting as co-existent tacrolimus toxicity. Most of our “new” patients have been transferred from the temporary ICUs as they have been decommissioned, and have become chronically critically ill with persistent inflammation, immunosuppression, and catabolism. Nosocomial infections are now common, and some of the transferred patients have multi-drug-resistant pathogens, a stark reminder of how important antimicrobial stewardship is in the ICU. Adrenal insufficiency is also common, usually presenting as an unexplained inability to wean from vasopressor therapy. Surprisingly, stress-related upper gastrointestinal hemorrhage, a rarity for the last 30 years or so, has reared its ugly head despite prophylaxis and aggressive nutritional support. Therapeutic anticoagulation is a contributing factor, but we have seen new-onset lower extremity deep venous thrombosis within 48-72 hours after holding heparin or enoxaparin, so the risk:benefit equation can be challenging to solve.

    Even as we continue to care for these patients, the conversation is changing. When will the hospital get back to business as usual? When will New York City reopen? The questions are related, and the answers remain obscure. As to the former, we still have but four operational ORs, but access to them is less restrictive. Acute care surgical volumes are recovering as people overcome their fear of coming to the hospital. As of today, we can operate again on uncomplicated acute appendicitis or cholecystitis if indicated.  Elective surgery is another story. As soon as the ORs and the post-anesthesia care units are restored from functioning as temporary ICUs (and it will be soon), we will be ready to go. Will we be enabled? The backlog department-wide is hundreds of cases.

    Studies of antibody testing in New York State reported on May 2 estimated that more than 20% of the downstate population and 12% of the upstate population have been infected, meaning that official case estimates may underestimate the true prevalence by a factor of 10 or more. Whether immunity is conferred by seropositivity remains unknown, but in the spirit of test-test-test, it seems we need to know before we can reopen. Criteria for political decision-making* as to when New York City will normalize are heavily oriented toward medical indicators. New York State has set seven criteria, four of which are met currently. We have had a 14-day decline in hospitalizations (1) and deaths (2). More than 30,000 tests/100,000 population have been performed in the last 30 days (3), and there are more than 30 “contact tracers”/100K population (4). Criteria not met are new hospitalizations fewer than 2/100K/day (currently 2.67) (5), proportion of hospital beds available > 30% (currently 28%) (6), and proportion of ICU beds available > 30% (currently 24%) (7). Two of the additional New York City criteria have been met: Hospital admissions are fewer than 200/day and the proportion of new, positive nasal swab tests is < 15%, but there are still 550 critical care patients in the hospitals run by the NYC Health+Hospitals Corporation, and the number needs to be < 375. Close, but how close?

    As the weather has improved and to battle cabin fever, I and my N95 mask and gloves have been venturing out a bit onto the streets of Manhattan. It’s still surreal-so little traffic that songbirds can be heard absent the din. People are out walking their dogs (you didn’t know that New York is a “dog town,” did you?). Lines formed outside grocery, drug, and hardware stores as people honor social distancing. Ice cream parlors and liquor stores, too (you know, the essentials!). Only a handful of people were not wearing masks, which to me seems an act of defiance (as in death-defying).

    We need to stay safe, and the country needs to get back to work. It will be Hobson’s choice.

     

    * Data source: https://gothamist.com/news/coronavirus-statistics-tracking-epidemic-new-york. Accessed May12, 2020.