Assume that everyone at the hospital has Covid-19 until proven otherwise.
“Team 700 to B4.”
Before Covid-19 took over our hospital, I may have heard this page — which summons a medical team because a patient’s heart has stopped — once or twice a week. In the past couple of days, I’ve lost count of how many times I’ve heard it.
One recent page stands out: It was the afternoon of March 23, for a male in his early 30s with no medical problems. We had maxed out on his ventilator settings yet his lungs couldn’t deliver the oxygen his body needed, so his heart had naturally stopped.
Over the past week, the hospital in Elmhurst, Queens where I’m a resident in emergency medicine has been inundated with coronavirus patients needing ventilators. On a typical day, we are one of the busiest emergency departments in the country. We take pride in serving one of the most diverse and vulnerable patient populations in the world. Esoteric and rare diseases are common occurrences here. Our sheer volume and diversity also meant that we were uniquely susceptible to a pandemic.
When the first case made its way to New York City, we suspected it was only a matter of time. However, we didn’t expect that we would become a “ground-zero” hospital for Covid-19.
Initially, we just had one patient with a high clinical suspicion for Covid-19, but over time, patients with relatively low or no clinical suspicion without fevers were turning out positive. We learned that the virus’s symptoms vary: Some presented with cholera-like diarrhea with profound dehydration that then progressed to respiratory distress, whereas others had mild headaches with muscle aches.
This taught us one of many valuable lessons early on. As other hospitals around the country prepare for the pandemic to arrive in the coming days, we hope that our first-hand experiences can help them avoid the same mistakes and pitfalls.
Here are six of the most important lessons we’ve learned so far:
1) Assume that everyone at the hospital has Covid-19 until proven otherwise
At the beginning of the pandemic, we underestimated the number of asymptomatic carriers that were admitted for unrelated reasons. We didn’t test these patients, as it wasn’t considered clinically indicated. A lack of testing kits compounded the problem. And the lack of early, widespread mobilization of personal protective equipment (PPE) made it even worse.
The scarcity of PPE meant that we were judicious in using it only for “persons under investigation” (PUI) for Covid-19. This soon proved to be a disastrous and futile policy.
We weren’t using protective equipment for unknown asymptomatic carriers and likely became reservoirs of transmission. It meant that nurses and doctors likely transmitted the disease silently, but to what extent remains largely unknown. The only way to prevent this transmission is by either testing all providers and patients each day or by using PPE for every patient. The latter strategy was far more practical.
2) It is impractical to isolate Covid-19 patients from non-Covid-19 patients
We tried to isolate PUI into our intensive care units (ICUs), but as the hospital became overwhelmed with PUIs, the policy had once again proven to be futile. This, coupled with a large turnaround time to get test results, meant we weren’t able to appropriately triage patients to Covid-19 and non-Covid-19 areas of the hospitals.
Though this may change with the availability of rapid-turnaround tests, the lack of sensitivity of the test made us cautious about sending patients to a non-Covid-19 unit. We thus came to a grim realization: The only way to minimize some transmission was to once again use our PPE for any and all patients.
Over the next several days, as we were coming to grips with our reality, we started seeing a staggering number of patients that needed ventilators. At the beginning of the pandemic, we had predicted that elderly patients or patients with chronic conditions would likely be affected more. Though that has largely been true, we also started increasingly seeing young patients with no medical problems in respiratory arrest, needing a ventilator.
3) Expand the number of ICU beds in your hospital, exponentially
For us, it meant hospital floors that weren’t equipped to manage ICU patients suddenly became mini-ICUs. Sections of the “fast track” in our ER were carved off into ICUs with vented patients. At one point, it even meant transferring patients to nearby hospitals with ICU beds.
Needless to say, that was short-lived as every hospital in NYC soon became inundated with Covid-19 patients. Frankly, we have even explored the option of turning operating rooms into ICUs. Just when we thought we had enough ICU beds, we needed more. My advice is to prepare for the worst and hope for the best.
4) Minimize the exposure to nurses and staff
As all the patients in the ICUs required multiple blood draws, titration of medications, and adjusting ventilator settings on an hour-by-hour basis, the staff had to find ways to minimize our overall exposure to the virus. Early on, we decided to place the ventilator as well as the IV poles outside of the patient rooms while also consolidating all of our critical care procedures in one sitting.
For us, it meant every vented patient had multiple peripheral IV accesses, a central venous catheter as well as an arterial line. This enabled the nurses and doctors to minimize their overall exposures.
5) Train essential clinical personnel in critical care medicine early
Expanding the physical space and bridging the equipment and testing shortages was one feat, but the unexpected shortage of clinicians and nurses trained in intensive care medicine was another. The sheer volume of patients coupled with nurses and doctors who fell ill to Covid-19 made this a penultimate issue.
In our hospital, training non-ICU nurses and non-intensive doctors in critical care medicine was simply not an option, but a necessity. It meant training cardiologists on complex vent management. Needless to say, when the ER doctors and intensivists fall ill, having a safety net of clinicians trained in parts of intensive-care medicine will be crucial for patient care.
6) Telemedicine is a critical way to decompress your ER and your hospital
As we were inundated with critically ill patients, we also saw an exponential rise in “worried-well patients” requesting an evaluation. Some hospitals have adopted telemedicine where doctors take turns answering questions from patients and triage them on whether they should be sent to the ER or not. This has proven to be effective in decompressing the ER, likely preventing patient-to-patient and clinician-patient transmissions.
However, in a hospital that serves some of the poorest patients like mine, telemedicine is simply not an option. For these hospitals, testing tents outside the hospital have proven somewhat effective, but still not enough to keep up with the demand.
Even with the best of these measures, as of April 1, 1,374 New Yorkers have lost their lives to Covid-19, more than 376 of them in Queens. One-third of the city’s total cases (45,672 as of April 1) are in Queens, too.
As the code team runs to the bedside, the team leader assigns members their roles. They press on the patient’s chest and push all the necessary medications to rescue his heart. After several minutes, just when we felt defeated, the patient’s heart started beating again. We sighed a sense of relief and looked at each other, knowing that it was only a matter of time until our next code.
Suresh Pavuluri is a resident physician with the Department of Emergency Medicine at the Icahn School of Medicine at Mount Sinai.
Author: Suresh Pavuluri
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