“Crew 700 to B4.” Earlier than Covid-19 took over our hospital, I'll have heard this web page — which summons a medical staff as a result of a
“Crew 700 to B4.”
Earlier than Covid-19 took over our hospital, I’ll have heard this web page — which summons a medical staff as a result of a affected person’s coronary heart has stopped — a few times every week. Up to now couple of days, I’ve misplaced depend of what number of occasions I’ve heard it.
One current web page stands out: It was the afternoon of March 23, for a male in his early 30s with no medical issues. We had maxed out on his ventilator settings but his lungs couldn’t ship the oxygen his physique wanted, so his coronary heart had naturally stopped.
Over the previous week, the hospital in Elmhurst, Queens the place I’m a resident in emergency drugs has been inundated with coronavirus sufferers needing ventilators. On a typical day, we’re one of many busiest emergency departments within the nation. We take delight in serving some of the numerous and weak affected person populations on the planet. Esoteric and uncommon illnesses are widespread occurrences right here. Our sheer quantity and variety additionally meant that we have been uniquely inclined to a pandemic.
When the primary case made its option to New York Metropolis, we suspected it was solely a matter of time. Nonetheless, we didn’t anticipate that we might turn into a “ground-zero” hospital for Covid-19.
Initially, we simply had one affected person with a excessive medical suspicion for Covid-19, however over time, sufferers with comparatively low or no medical suspicion with out fevers have been turning out optimistic. We realized that the virus’s signs differ: Some offered with cholera-like diarrhea with profound dehydration that then progressed to respiratory misery, whereas others had gentle complications with muscle aches.
This taught us certainly one of many invaluable classes early on. As different hospitals across the nation put together for the pandemic to reach within the coming days, we hope that our first-hand experiences may also help them keep away from the identical errors and pitfalls.
Listed below are six of an important classes we’ve realized thus far:
1) Assume that everybody on the hospital has Covid-19 till confirmed in any other case
In the beginning of the pandemic, we underestimated the variety of asymptomatic carriers that have been admitted for unrelated causes. We didn’t check these sufferers, because it wasn’t thought-about clinically indicated. A scarcity of testing kits compounded the issue. And the shortage of early, widespread mobilization of non-public protecting tools (PPE) made it even worse.
The shortage of PPE meant that we have been even handed in utilizing it just for “individuals underneath investigation” (PUI) for Covid-19. This quickly proved to be a disastrous and futile coverage.
We weren’t utilizing protecting tools for unknown asymptomatic carriers and certain grew to become reservoirs of transmission. It meant that nurses and medical doctors possible transmitted the illness silently, however to what extent stays largely unknown. The one option to forestall this transmission is by both testing all suppliers and sufferers every day or by utilizing PPE for each affected person. The latter technique was way more sensible.
2) It’s impractical to isolate Covid-19 sufferers from non-Covid-19 sufferers
We tried to isolate PUI into our intensive care items (ICUs), however because the hospital grew to become overwhelmed with PUIs, the coverage had as soon as once more confirmed to be futile. This, coupled with a big turnaround time to get check outcomes, meant we weren’t capable of appropriately triage sufferers to Covid-19 and non-Covid-19 areas of the hospitals.
Although this may increasingly change with the supply of rapid-turnaround assessments, the shortage of sensitivity of the check made us cautious about sending sufferers to a non-Covid-19 unit. We thus got here to a grim realization: The one option to reduce some transmission was to as soon as once more use our PPE for any and all sufferers.
Over the subsequent a number of days, as we have been coming to grips with our actuality, we began seeing a staggering variety of sufferers that wanted ventilators. In the beginning of the pandemic, we had predicted that aged sufferers or sufferers with persistent circumstances would possible be affected extra. Although that has largely been true, we additionally began more and more seeing younger sufferers with no medical issues in respiratory arrest, needing a ventilator.
3) Broaden the variety of ICU beds in your hospital, exponentially
For us, it meant hospital flooring that weren’t outfitted to handle ICU sufferers all of a sudden grew to become mini-ICUs. Sections of the “quick observe” in our ER have been carved off into ICUs with vented sufferers. At one level, it even meant transferring sufferers to close by hospitals with ICU beds.
For sure, that was short-lived as each hospital in NYC quickly grew to become inundated with Covid-19 sufferers. Frankly, we now have even explored the choice of turning working rooms into ICUs. Simply after we thought we had sufficient ICU beds, we would have liked extra. My recommendation is to arrange for the worst and hope for the most effective.
4) Decrease the publicity to nurses and employees
As all of the sufferers within the ICUs required a number of blood attracts, titration of medicines, and adjusting ventilator settings on an hour-by-hour foundation, the employees needed to discover methods to reduce our total publicity to the virus. Early on, we determined to put the ventilator in addition to the IV poles outdoors of the affected person rooms whereas additionally consolidating all of our crucial care procedures in a single sitting.
For us, it meant each vented affected person had a number of peripheral IV accesses, a central venous catheter in addition to an arterial line. This enabled the nurses and medical doctors to reduce their total exposures.
5) Practice important medical personnel in crucial care drugs early
Increasing the bodily house and bridging the tools and testing shortages was one feat, however the surprising scarcity of clinicians and nurses skilled in intensive care drugs was one other. The sheer quantity of sufferers coupled with nurses and medical doctors who fell ailing to Covid-19 made this a penultimate problem.
In our hospital, coaching non-ICU nurses and non-intensive medical doctors in crucial care drugs was merely not an choice, however a necessity. It meant coaching cardiologists on advanced vent administration. For sure, when the ER medical doctors and intensivists fall ailing, having a security web of clinicians skilled in elements of intensive-care drugs will likely be essential for affected person care.
6) Telemedicine is a crucial option to decompress your ER and your hospital
As we have been inundated with critically ailing sufferers, we additionally noticed an exponential rise in “worried-well sufferers” requesting an analysis. Some hospitals have adopted telemedicine the place medical doctors take turns answering questions from sufferers and triage them on whether or not they need to be despatched to the ER or not. This has confirmed to be efficient in decompressing the ER, possible stopping patient-to-patient and clinician-patient transmissions.
Nonetheless, in a hospital that serves among the poorest sufferers like mine, telemedicine is just not an choice. For these hospitals, testing tents outdoors the hospital have confirmed considerably efficient, however nonetheless not sufficient to maintain up with the demand.
Even with the most effective of those measures, as of April 1, 1,374 New Yorkers have misplaced their lives to Covid-19, greater than 376 of them in Queens. One-third of the town’s complete circumstances (45,672 as of April 1) are in Queens, too.
Because the code staff runs to the bedside, the staff chief assigns members their roles. They press on the affected person’s chest and push all the mandatory drugs to rescue his coronary heart. After a number of minutes, simply after we felt defeated, the affected person’s coronary heart began beating once more. We sighed a way of aid and checked out one another, figuring out that it was solely a matter of time till our subsequent code.
Suresh Pavuluri is a resident doctor with the Division of Emergency Drugs on the Icahn College of Drugs at Mount Sinai.