A View from New York City: Thoughts from a COVID – 19 Hotspot

Sanjum Sethi MD, MPH¹

¹Columbia University Irving Medical Center, New York Presbyterian Hospital

Corresponding Author:
Sanjum S. Sethi MD, MPH
Assistant Professor of Medicine
Center for Interventional Vascular Therapy
161 Fort Washington Ave Fl 6
New York, NY 10032
Telephone: 212 305 7060
Email: [email protected]

DOI: 10.48107/CMJ.2020.05.002

Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.

The Rise of SARS-CoV-2 and Early Preparations

One day I entered the hospital and there was a certain buzz in the air.  Quickly it became clear; we had our first case a patient infected with SARS-CoV-2 virus in the building.  No longer was this a remote possibility.  We must prepare and we must prepare quickly.

The next several weeks were a flurry of activity.  Elective surgeries and cardiac catheterization procedures were cancelled.  Not only to preserve personal protective equipment, but also to preserve hospital beds for the incoming influx of patients.  We started rescheduling stable outpatient clinic visits, triaging those who needed to be seen urgently while quickly ramping up our telehealth services to provide access to our patients.  We sent our staff to work from home and urged our clinicians to stagger their schedules.

Despite these preparatory steps, the sheer volume of patients admitted with critical illness in such a short time was beyond what could have been predicted.  Intensive care units (ICUs) quickly became full.  The entire hospital became a monolithic entity, treating one illness.  An ICU expansion took place.  Our anesthesia colleagues converted the operating rooms into ICU beds.  Walls went up in our cardiac catheterization laboratory holding area.  It became an ICU almost overnight.

After creating the beds, we needed clinicians to take care of these COVID-19 patients.  Everyone was redeployed.  Some manned fever clinics, others did emergency rooms shifts.  I was assigned to the ICU.  I was the attending in the surgical ICU (SICU) with an anesthesia fellow, a pediatric pulmonary fellow, a psychiatry resident, and an orthopedic intern.  As our anesthesia colleagues were needed to cover the new OR ICUs, redeployed clinicians filled in for them in the SICU.  The unit was surgical in name only.  Every ICU was taking care of the same disease.

Going on Service

I came for signout.  This was a COVID-19 unit taking care of patients intubated with ARDS respiratory failure.  Extubations had been rare.  The residents had quickly become experts in the disease.  The patterns became all too familiar.  Lymphopenia, fluffy infiltrates on the chest x-ray, severe hypoxemia and elevated inflammatory biomarkers were standard features of every admission.  The patients were from all backgrounds and all ages with the vast majority being functional prior to their critical illness.

While we accommodated to the new normal clinically, the university was hard at work gathering data as quickly as possible.  Early reports were coming out of China and Italy regarding key topics in management.  Clinical protocols were being updated almost daily to keep up with latest research studies.  However, the truth became obvious rather quickly.  There was no magic bullet treatment for this disease, at least not yet.

Several features were immediately striking as we rounded on our patients.  This was a vicious disease.  Multiorgan dysfunction was common and practically expected.¹  Most were ambulatory with only minor problems in their past medical history.  The patients were generally intubated for respiratory failure, but were soon suffering from renal failure, coagulation disorders, and cardiac manifestations.  There was a preponderance of high BMI patients.  Early data from across New York City confirms this observation with obesity being a risk factor for a more severe hospital course.^2-4  Lengths of stay are long.  Many of the patients had already been in the ICU for several days prior to my starting.  Unfortunately, once intubated, the prognosis is poor.  One institution confirmed an 88% mortality once intubated (which may end up being lower, since many of their patients were still intubated at the time of publication).²

Treatment Options

We are all aware that there is no vaccine for this illness.  Further, as a medical community, we are still determining the reasons why certain patients develop severe illness and others have mild disease or are even asymptomatic.  Our infectious disease team continues to advise us on the best treatments based on ongoing changes in evidence both with regards to antivirals such as hydroxycholoroquine and remdesivir as well as medications directed at the cytokine storm such as tocilizumab.  While there have been some promising reports, none of these treatments has enough evidence to suggest routine use.  Particularly troubling are reports of harm both in terms of cardiac arrhythmias and Steven Johnsons syndrome, which suggests careful patient selection by specialists prior to administration of any therapy.⁵  The most recent NIH guidelines suggest most of these commonly touted pharmacologic therapies be administered in the setting of a clinical trial.⁶

Thrombotic complications are common in the critically ill COVID-19 patients.  Nurses frequently reported filters used in continuous renal replacement therapy clotting.  One French center found rates of filter clotting to be greater than 95%.⁷  Dialysis catheters and central venous catheters thrombosed frequently as well despite appropriate prophylactic dose anticoagulation.  As a member of our institution’s pulmonary embolism response team, we have seen a significant increase in the number of consultations for both deep vein thrombosis and pulmonary embolism.  Early data suggests that hemostatic dysregulation occurs.⁸   Venous thromboembolism may occur in up to 30% of patients.^9,10  However, empiric anticoagulation can lead to the serious risk of bleeding complications.  Multiple ongoing trials will help understand the level of anticoagulation necessary for specific patients.

The impact of this experience cannot be easily described.  This disease is horrific and its impact on patients and families cannot be understated. Being unable to visit, families have to rely on periodic phone calls or video conferencing to see their loved ones.  Funeral planning is limited or nonexistent.  Healthcare workers are stretched to the limit both physically and emotionally.  Despite the obvious depravity, a few bright spots are also present.  Many across the medical center have channeled the experience into action.  Research continues at a feverish pace as we need to find solutions both in terms of therapies as well as vaccines.  Despite this harrowing experience, the tenacity and resilience of the frontline healthcare workers such as nurses, respiratory therapists, physician assistants, nurse practitioners, residents, fellows, and others are truly limitless and inspiring.  Their collective spirit in persevering and offering our patients the best care possible provides us hope in ultimately overcoming this disease.

References

1. Siddiqi HK and Mehra M. COVID-19 Illness in Native and Immunosuppressed States: A Clinical-Therapeutic Staging Proposal. J Heart Lung Transplant. March 2020. https://doi.org/10.1016/j.healun. (Accessed 12/03/2020).
2. Richardson S, Hirsch JS, Narasimhan M et al. COVID-19 Research Consortium. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area.  JAMA April 2020.
3. Petrilli C, Jones SA, Yang J et al. Factors associated with hospitalization and critical illness among 4,103 patients with COVID-19 disease in New York City medRxiv 2020.04.08.20057794; doi: https://doi.org/10.1101/.20057794 (Accessed 08/04/2020).
4. Cummings M, Baldwin M, Abrams D et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. medRxiv 2020.04.15.20067157; doi: https://doi.org/10.1101/.20067157 (Accessed 15/04/2020).
5. Lane JCE, Weaver J, Kostka K et al. Safety of hydroxychloroquine, alone and in combination with azithromycin, in light of rapid wide-spread use for COVID-19: a multinational, network cohort and self-controlled case series study medRxiv 2020.04.08.20054551; doi: https://doi.org/10.1101/20054551 (Accessed 08/04/2020).
6. National Institute of Health. COVID-19 treatment guidelines. https://www.covid19treatmentguidelines.nih.gov/
7. Helms J, Tacquard C, Severac F et al. High risk of thrombosis in patients in severe SARS-CoV-2 infection: a multicenter prospective cohort study. J Intensive Care Med 2020;doi:10.1007/s00134-020-06062-x
8. Thachil J, Tang N, Gando S et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost. 2020. DOI: 10.1111/JTH.14810
9. Cui S, Chen S, Li X et al. Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia. J Thromb Haemost. 2020 Apr 9.
10. Klok FA, Kruip MJHA, van der Meer NJM et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020 Apr 10. pii: S0049-3848(20)30120-1. doi: 10.1016/j.thromres. (Accessed 13/04/2020).