• APR 23, 2020

    Work and Life in the Bubble

    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

    I just finished a stint covering two surgical ICUs at night, including the “line team.” It’s hard work, with a lot of running around, putting our fires here, there, and everywhere. Not to mention managing the new admissions, although those are fewer now that we are “post-peak.” It’s rather amazing what goes on at night, when there are fewer “grown-ups” around; perhaps that’s a story for another time. What shall be the subject of today’s discourse? Those who know me recognize that I am seldom short of opinions or at a loss for words, whether orally or on the printed page. So here is more of the same, about more of the same.

    We’re still quite busy as we had anticipated, although a bit less so since the peak around 10 days ago (April 15, give or take.) At the peak, we had 480 hospitalized COVID-19 patients in our shop, of whom 218 (45%) were in an ICU and 212 (an astonishing 97%) required mechanical ventilation. At that time, 44 or so (~20%) were under our care in two authentic ICUs and one temporary facility (since decommissioned, earlier this week). This morning, hospitalized patients are 22% fewer but only 10% fewer in ICUs; 95% of whom (186/196) still require mechanical ventilation. That is consistent with something we have come to learn about COVID-19 and its severe manifestations: Most intubated patients require several weeks of mechanical ventilation, and the “washout” of the mechanical ventilation curve is predictably flat.

    As the workload has begun to decrease, there has been the opportunity to peek at the outside world via traditional and social media (although I am not much for the latter). It seems to me as if there are two separate worlds on the same planet.

    New York City is still (rightly, with now more than 150,000 confirmed cases) in near-lockdown, with mask wearing required outdoors by administrative fiat. Our stay-at-home order has been extended to May 15. Inside my bubble, life is mostly a cycle of work eat-sleep-eat-work with personal hygiene mixed in here and there (wash-rinse-repeat), but fuggetaboutit if you need a haircut (unless you’re handy with Metzenbaum scissors and a mirror.) New York State just announced that only hospitals in the 10 least-affected counties (all upstate and rural-a natural experiment in social distancing?) are going to be allowed soon to resume elective surgery. We are worried about our patients, ourselves, and how to teach our residents when there is so little operating to be done. At least they are learning a LOT of critical care.  

    There is a lot of critical care. The patients remain on ventilators for a long time, and the threat of airway obstruction from mucus plugs and airway debris is ever-present. The “authorities” are nervous about us performing bronchoscopy out of fear of the “COVID cloud” that is created, but there are times we must as a life-saving intervention. We are in the midst of a “trach-a-thon,” perhaps one hundred or more tracheostomies already, although we haven’t started counting. Yet. The interface between renal failure and the mysterious hypercoagulable state is horrific; sometimes even therapeutic heparin anticoagulation and maximal blood flow rates cannot protect the venous catheter or the filter of the dialysis machine from thrombosis. We are fortunate to get eight hours of use (normally, up to 72 hours) from a filter before it clots. We have gone through hundreds of filters, but fortunately we are not running low. Yet. Nosocomial bacterial infections are starting to rear their ugly heads, mostly pneumonia but bacteremia as well. The pathogens are mostly gram-positive. We use linezolid empirically, because it is so challenging to dose vancomycin when never sure how effective a particular day’s session of renal replacement therapy is going to be. Fortunately we are not seeing multi-drug-resistant gram-negative pathogens. Yet.

    As for me, I am OK. High professional satisfaction and outstanding support from colleagues and friends is tempered greatly by the fact that I have not been home in nearly five weeks. My beloved is an asplenic survivor of lymphoma; the risk to her posed by my presence right now would be too great.

    Remember, every one you meet is fighting a battle you know nothing about. Now more than ever, be kind.