Letter from NYC: Lessons learned ahead of possible future waves of COVID-19

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Nicholas J. Morrissey

On March 1, I drove down the Connecticut Turnpike in a rental car with my three sons. We had just left a somber family event, and I was listening to the news with eagerness as the initial COVID-19 invasion of the Pacific Northwest seemed poised to overflow across the United States. The first potential New York patient was being tested, while one confirmed case was identified in Rhode Island. After that peaceful day, the next two months exist in my mind’s eye as a blaring tidal wave of pain, death and unrest.

The second case, in Westchester County, was located a mere 15 minutes outside the city, and, given the early stage of the U.S. experience, testing and isolation were well under the radar. The patient’s travels were vast and inoculating. Symptomatic and asymptomatic carriers logarithmically rained this disease to the south, where our most vulnerable and physiologically susceptible lived in high density. This was the beginning of the disparate destruction of people by the single-stranded RNA virus, apparently bringing the most modern civilization to its knees.

So many societal issues illuminated by the COVID-19 flashlight were on display from day one. The haves whose jobs were not essential fled to their well-spaced out homes away from the cesspool of virus—often to the dismay of the natives who feared Gotham’s invasion would bring virus to their miniscule healthcare system.

Here in Manhattan—or, more precisely, here at Columbia University Irving Medical Center—the mission was clear. Daily predictions assured us we were in for an onslaught of sickness and contagion unlike any that had been seen in a century. The department of surgery faculty, without hesitation, offered up their services to be redeployed in any capacity the strategists felt appropriate.

MEDICAL SWAT

A team of acute care surgeons and general surgery residents invented the SWAT team—Surgical Workforce and Access Team. The group was staffed 24/7, and included an attending and two residents. Almost all surgeons took their share of 12-hour shifts, deploying to the emergency department and to the various intensive care units (ICUs) that were constructed hastily yet efficiently in all corners of our institution. We placed several hundred lines, tubes, etc. One thing to bear in mind—peculiar

to our institution—is that the entire hospital enterprise had just a month earlier gone live with the Epic electronic medical record (EMR) across all campuses. It was an impressive lift to get all practitioners up to speed and working on Feb. 1, and the onslaught of a global pandemic threatened to overwhelm the nascent facility we demonstrated with our new tools. What happened from March forward was fairly remarkable. Epic natives constructed COVID-19 specific workflows, helping bring the naïve up to speed rapidly. Pandemics and public health crises are not things we celebrate, but our responses to them can and perhaps should be. My institution, in ways even beyond the spirit suggested in this writing, performed admirably and with complete support in ways that make me exquisitely proud.

The faculty in all departments rapidly assimilated and selflessly redeployed around the institution in varying roles. The department of surgery faculty spent weekend free time reviewing critical care and ventilator management in preparation for taking on roles in the ever-burgeoning ICUs.

POP-UPS

Early on in the process, while we saw the onslaught steaming towards us from afar, almost the entirety of our operating room (OR) suites were converted to pop-up ICUs. I still recall the first moment I peered into “my” OR. The surgical lights were unceremoniously pushed toward the ceiling, made unnecessary by the retooling of this once familiar space. The tape on the floor outlined space for up to six beds, and the ventilators of varying sizes and shapes were at the ready. Ventilators were to be our limiting factor, this was the message we received from Italy and our governor. Every available anesthesia machine was quietly placed in position alongside beds topped with crisp linens: the calm before the swarm. Within a week, I began the first of about 15 ICU shifts. We all volunteered in one way or another for these 12-hour shifts.

That first night was surreal. My “room” was now full. The beds contained intubated, sedated patients with feeding tubes, towers of drips and renal replacement modules. The noise of the airflow systems was a deafening reminder of just how quickly and completely our native spaces were turned into unrecognizable entities. The space, the lights, the scrub sink all immediately reminded me that, yes, this is where I now live.

Every shift brought new experiences as we responded to data learned from the previous
few days: treatments, vent weaning, sedation, coagulation, cardiomyopathy, renal failure. The N-95 masks, always present, gave rise to hypercarbic headaches post-shift—only the first layer in the uniform of safety. Surgical masks were followed by bouffant cap and face shield. Anxiety peaked when you entered a room without these pieces of equipment. Or perhaps when an endotracheal tube disconnected such that the HEPA filter was not

on the patient side. Many weeks later, as I remain healthy and do my 9-mile runs to assure lung function is intact, I am convinced that I was perhaps safer swimming in the COVID-19 broth than many of my fellow citizens meandering on the outside.

TRANSFORMED

One evening, I donned my layers of personal protective equipment (PPE) and placed an iPad into a Ziploc-type apparatus. I walked into the room and pushed a button to connect via FaceTime to a patient’s wife. It was Easter weekend. I held the screen to his face, and she saw him, intubated and asleep. She wept and prayed, in Spanish reassuring him that she had recovered from her COVID-19 bout and that the children and grandchildren were doing fine. So many times she said, “I love you,” and her tears flowed in HD across the screen. I was as close as I could be to his face to try to minimize the infinite distance between the two loves. I looked around the space, the space in which a year ago,

at 2 a.m., a fellow and I repaired a gunshot wound to an axillary artery with a saphenous vein graft. This same space so transformed—unrecognizable save for the obvious small, well-placed landmarks that made it unmistakably “my” room. That was our first face-to-face patient-family encounter, and I recounted it to my colleagues as perhaps the most emotionally intense moment of my career. I can report that, after several weeks, this gentleman was reunited with his family, in person, at home.

On a personal level, my three sons, teenagers all, who were being educated via Zoom and web- based classes, certainly had to be protected from my potential as a vector of disease. As with many of us, a decision was made to have my parental relationship exist via FaceTime, with daily chats, homework help and discussions that normally occurred in person. It’s a small price to pay to protect them from some of the ravages we are only just detecting regarding pediatric COVID-19.

My personal situation did not require a reconfiguring of living arrangements but several colleagues ended up holing up in dorm rooms and other temporary housing in order to engage in the mission while protecting their families. I suspect my experience is echoed around the country and the world. In wave one, we seemed to be running a few steps ahead of the tidal wave. I am hopeful that if there are more, what we have accumulated in knowledge, equipment and collaborative spirit will keep us comfortably ahead of the onslaught.

Nicholas J. Morrissey, MD, is associate professor of surgery in the division of vascular surgery at Columbia University Vagelos College of Physicians and Surgeons in New York.

1 COMMENT

  1. Nick – you know I love you. I am so proud of you, I am so glad you are OK. I hope you get to immerse yourself with quality memory making times with the boys. Thank you for all you do, before this experience and even thereafter. Your mom and dad are so so so proud of you, and I am beyond thrilled to say I know you and call you friend.

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