A Mass Casualty In Slow Motion: Emergency Medicine During the COVID-19 Surge in New York City

 

The first time I really took notice of coronavirus was when a few providers started wearing masks during their shifts. This was in mid-February when the virus was a Wuhan problem, and we were screening people with travel questions. If you weren’t recently in Hubei Province, weren’t in contact with someone recently in Hubei Province, and weren’t in contact with someone known to have coronavirus, you were deemed to not have coronavirus. If you screened positive on any of those criteria, we got on the phone with our city department of health, and if they agreed, they coordinated testing with Atlanta; at that time only the CDC had a diagnostic test for SARS-CoV-2. I asked my colleague Matt why he was wearing a mask. His response: You don’t think it’s coming here?

I’m pretty sure I hadn’t contemplated that question, until that moment. Meanwhile, our hospital administration was discouraging us from wearing masks, because they are needed for surgeries, and because it presents badly. Meanwhile, boxes of masks started disappearing. 

It wasn’t long after that, early March, when the well patients started coming in, mostly with fever but also chest pain, gastrointestinal symptoms, fatigue, and of course shortness of breath. Most of them were doing fine, ambulatory. They wanted to be tested for coronavirus. During this period we had some tests, then we had no tests, then we had tests, then no tests. We set up a “COVID clinic” across the street from the ED to keep these patients away from the department and process them quickly. Almost all of them were discharged home, with or without a test.

A small number of these early patients were sicker, and needed oxygen, so they had to be admitted. We started to notice alarmingly low saturations, much lower than expected for their clinical condition. We were doing a lot of chest xrays and labs, and some chest CTs. Nearly all these chest CTs showed bilateral ground glass opacities. COVID pneumonia. There was no treatment for COVID pneumonia, but there was a suggestion that hydroxychloroquine was effective, so we treated everyone with hydroxychloroquine. These patients were put in isolation rooms, which quickly filled up throughout the hospital, so they were boarding in the ED, waiting for an iso room.

It was becoming clear that circumstances in Italy were dire, and Italy isn’t China, Italy is across a much smaller ocean. NYC hospital administrators began to grasp the magnitude of the problem and were furiously trying to increase capacity. Elective surgeries were canceled and all the PACUs became ICUs, as did the ORs, then the cafeterias. Tents started going up outside the hospital. The first of three refrigerated trucks arrived. 

We separated the ED into cold and hot zones. In the hot zone, we were wearing N95s. Providers who had contact with patients who were found to be COVID+ were quarantined for 14 days. This seems so quaint in retrospect.

The arriving patients started getting sicker. The paradigm at the time was that if the patient was not stabilized with low-flow oxygen (6 liters/min nasal cannula),  they should be intubated. This was based on the notion that these patients would all end up requiring intubation anyway, and noninvasive high-flow oxygenation strategies such as high flow nasal cannula (HFNC) and NIV (CPAP/BiPAP) would aerosolize virus, infecting providers and other patients. We had never seen this disease before, so we accepted the intubate early paradigm, and sent dozens of intubated patients to the ICU in the first days of the surge, at least five times as many ICU admissions as usual.

By mid-March, we were practicing in disaster mode, our threshold to admit went way up. We stopped doing tests on patients who obviously had COVID but were ok–if you didn’t need oxygen, you went home, come back if you can’t breathe. At this point everyone in the ED is wearing cap, goggles, N95, surgical mask, gown and gloves their entire shift, regardless of where they were stationed in the ED. There were still nominally hot and cold zones but we all knew that was pointless because everyone had COVID, which we were diagnosing primarily by CT. Every patient with fever and respiratory symptoms had peripheral ground glass opacities, but, as time went on, every patient regardless of their symptoms had peripheral ground glass opacities. And we were doing CT chest on a lot of patients, because the upstairs teams for a while thought they could separate the COVID from the not, but then some non-COVID patients who came in with, for example, appendicitis, turned out to have COVID. And so we were asked to start doing a lot more CT chests, and they all showed COVID. I saw a middle aged man who was on mile 40 of a 60 mile bicycle ride, came in in full spandex after getting hit by a car, fractured femur. No chest complaints, fever, nothing. Was on a 60 mile bike ride. CT chest: peripheral ground glass opacities. That was when I realized how prevalent COVID was in New York City. On March 20, Governor Cuomo announced that starting two days later, March 22, New York State would go on lockdown.

Health care providers started getting sick with COVID. One of our docs, a healthy, active woman in her 30s, who intubated 6 patients in one shift, ended up in the ICU (she went home, is doing ok now). The PPE shortage captured the attention of the entire country. We had enough PPE for everyone to use one set of PPE per shift; this was of course PPE designed to be discarded after a single patient encounter. It is very unpleasant to wear PPE for an entire shift. It’s hard to breathe in a mask, it’s a pain to eat or drink or pee so you are less likely to do any of those things. Nobody can hear anyone so everyone’s shouting and misunderstanding, and of course the pressure sore on the bridge of your nose, a painful badge of honor.

On March 27 I retweeted my colleague Cameron’s video showing a pulse ox saturation of 44% with otherwise normal vitals. I suggested, “Consider withholding intubation in hypoxic patients who are otherwise OK.” Some folks who had noticed the same thing chimed in in agreement, but most of the replies were skeptical or disparaging. Over the next days, however, scores of providers broadcast similar findings, including another one of my colleagues, Eric, who photographed a woman texting comfortably with a saturation of 54%. Enter the term happy hypoxemic, and within a week, no one doubted that this was happening, that this was some strange feature of COVID. This was when we, as a community, started to question the early intubation strategy, especially given the outcomes of intubated patients emerging from China and Italy. We began to see intubation as something to be avoided until unequivocally required, and started using HFNC and NIV to manage critically ill COVID patients, despite the aerosolization concerns. 

That said, everyone was freaking out about aerosolization concerns. At least 100 aerosol-responsible intubation checklists were unleashed onto the world. The intubation box was born, and will hopefully soon die. Some hospitals allowed HFNC but not NIV, some hospitals allowed NIV but not HFNC. Some hospitals allowed neither, so everyone in those shops got intubated.

Everyone was freaking out about cardiac arrest. Chest compressions and bag mask ventilation were thought to be high risk for aerosolization, and since we were learning from Italy and China that so many who got intubated for COVID died, some in the EM community suggested that all patients who arrived to the ED in cardiac arrest should be immediately pronounced without resuscitation attempts. Fortunately this solution did not carry the day, and we developed techniques for balancing our responsibility to patients and our own safety. Our protocol is to halt chest compressions and rescue ventilation as soon as EMS arrives, until two fully-PPE-donned providers place an LMA attached to a viral filter; cardiac arrest care can then proceed as usual.

Everyone was freaking out about ventilators. Every day the media came up with some way to make a story out of physicians deciding who lives and dies because we don’t have enough ventilators, even though no hospital actually ran out of ventilators. I was asked to write the institution’s ventilator allocation policy; we didn’t need it and I don’t think anyone ever read it. We all had to learn to use a variety of newly acquired ventilators, and ventilators are tricky.

Everyone was lionizing healthcare workers, who, while the rest of the country was learning how to bake bread on lockdown, were going to work in a lake of coronavirus, putting themselves in harm’s way to care for the severely afflicted. Every media outlet was desperate for any frontline doc to tell them how terrible the situation is, and how terrible their lives are. Nevermind that putting themselves in harm’s way is what firefighters and police do every day (for much less money and esteem), nevermind that healthcare workers have a job and continued income while so many others were suddenly in dire financial straits, nevermind that being trapped at home feeling useless is for lots of folks harder than going in to work, even when your work is more challenging than usual. I noticed that shifts that were vacated (generally for providers getting sick) were immediately snatched up, much faster than usual. Some of this was camaraderie in a disaster, but some of it was: if I’m not at work, I’m trapped at home with my family, I’d rather be at work. Meanwhile, at 7p every day in NYC, everyone claps and celebrates healthcare heroes. I think the focus of attention shifted a little too much to healthcare heroes.

I did appreciate getting messages (and cookies, and brisket) from 100 people I hadn’t heard from in ages. 

Well patients stopped coming to the ED, and sick patients too. Strokes, MIs, opioid overdoses, mostly disappeared. It’s distressing to think about what happened to them.

In the last week of March, the emergency department became a place familiar only to those who do battlefield medicine. The census was lower than usual, but every patient who presented was extremely sick. There were no ICU beds left in the city, so critically ill patients started accumulating in the ED. And were they ever critically ill–these patients had oxygen requirements we had never seen before. They came in saturating in the 50s, we put them on HFNC and their sats went up, but as soon as the cannula fell off, the saturation would drop down to nothing, in seconds. We then understood why everyone was getting intubated in China and Italy.

The emergency department was now a huge, open ICU, filled with patients who were either intubated or on HFNC/NIV, and the patients on HFNC/NIV required more intensive care than the intubated patients, because they’re awake. They turn to one side and the cannula falls off, causing a sudden emergency. They need to use the restroom. They want to talk to their families, who are not allowed in the hospital. The ICU teams were overwhelmed upstairs and in fact all the doctors in the hospital were now repurposed to intensive care, with orthopedic surgeons adjusting vents. So we in the ED were on our own managing a sea of critically ill patients, and we had to pretend to be intensivists too. 

We learned that we could improve oxygenation by having these patients flip on their bellies. Awake proning was born, and a few days and some thousands of tweets later, everyone was awake proning their patients. 

The patients who seemed stable enough to go to a non-ICU setting upstairs often turned out to not be. Code blues were called overhead seemingly every 30 minutes. We learned that the HFNC/NIV patients simply could not be managed on wards behind closed doors, and the ICUs could only accommodate intubated patients, so we stopped admitting the HFNC/NIV patients. We formed our own “ED Admitting Team” and admitted the patients to ourselves, they stayed downstairs and we just watched them as closely as we could, never knowing when to intubate them. Some of these patients after many days on HFNC/NIV could be downgraded to low-flow oxygen and admitted safely, but many got intubated. One young man was prone on HFNC on an ED stretcher for 12 days, and he never turned the corner. We pulled the trigger and intubated him, he went upstairs and was immediately put on ECMO. He was with us for 12 days, we all got to know him and were collectively heartbroken to send him to the ICU on a vent.

There was a period of a couple weeks where the demand for intensive care resources so exceeded supply that the shifts felt like walking through a fog, moving from one dying patient to the next. The absence of any scientific guidance made us feel and behave like helpless homeopaths. We had no effective therapies so we threw all sorts of likely ineffective therapies (azithromycin, hydroxychloroquine, zinc, vitamin C, steroids, nitric oxide, prostacyclin, convalescent plasma, remdesivir, tocilizumab) at them. No one in the world knew when these patients needed to be intubated or how to manage the vent once they were intubated. Saturations in the 70s felt normal, pronouncing patients dead proceeded like a drumbeat, and there were moments when it perversely felt like a relief. Perhaps because we had never felt like we could do so little for so many who needed so much, there were moments when it seemed better to be dead than be a dying patient in a pandemic-overwhelmed hospital with your loved ones not allowed to visit, your care coordinated by doctors powerless to stop the disease laying waste to your lungs.

On April 11 I was much more tired than usual; the next day I was on shift and developed a pounding headache, I never get headaches. When I got home late in the evening I felt awful and that was when I realized. The next day was like a truck hit me. Sweats, chills, nausea, no appetite, no energy, aching all over. I told my boss I had coronavirus. My boss said you need to come in and get tested. I said why, I know I have coronavirus, I feel like shit, I don’t want to come in and get tested. He said you need to come in and get tested. I went in and got tested. Days #4 and #5 were the worst. I barely got out of bed. Constant high fevers, debilitating headaches, dizzy whenever I tried to stand up. I ate nothing. But the worst part was the uncertainty about how things would go over the next week; lots of healthy young healthcare workers were getting very sick and I’ve seen more than a few people my age killed by covid. My test came back positive. Things were a little bit dark. I was anxious and miserable. On day #6 I started to feel a bit better, and I very slowly improved over another week, until I could do my usual activities again. It was the sickest I’ve ever been, but no complaints, I feel fortunate. 

The surge abated in mid-April, but the arrivals numbers remained very low, everyone in the community (rightfully) scared to come to the hospital. Many of the admitted patients were discharged, and many died. Most of the ED patients went upstairs. 

Now the department is slow. There is still coronavirus, lots of people dying of coronavirus upstairs, and still people dying of coronavirus downstairs, and we expect this to continue for many months, but now we can handle the volume. And we have a lot more experience managing COVID, though still very little science to guide us.

The countrywide lockdown is a mitigation strategy designed to flatten the curve so that hospitals aren’t overwhelmed and so we can transition to a containment strategy which requires the development of a robust test/trace/isolate infrastructure. Americans were frightened by what they saw in NYC, so they isolated much better than anyone predicted, and we flattened the curve better than anyone predicted. But a sophisticated and committed federal government response is needed to quickly build a test/trace/isolate infrastructure, and that hasn’t happened and looks like it’s not going to happen.  So most states, including New York, are nowhere near ready to come off of lockdown, from a public health perspective. But the public won’t tolerate this much longer, so we’re going to open up, and new cases/deaths will start to rise. As long as most of the dead are old, and we don’t see conditions like the mass casualty that was visited upon New York City for three weeks in March and April, I think most americans will trade a steady stream of deaths for an open economy. And that’s what I think will happen, until we get a vaccine, a cure, or herd immunity. I hope this is a once in a lifetime event. For untold hundreds of thousands, it definitely will be.

 

Thanks to Lois Isaksen, Michael Turchiano, Nick Schwartz, Josh Schiller, Matt Friedman, Eric Lee and Ram Parekh for their review and suggestions. 

Illustration by Lian Chang