SEATTLE—We live in unprecedented times. On Jan. 19, patient zero arrived in the United States at Seattle-Tacoma International Airport after returning from a visit to his family in Wuhan, China. He tested positive for COVID-19 on Jan. 20. Fast forward one month, and the heroic efforts of Helen Chu, MD, at the University of Washington, who, despite running against a cease-and-desist order by the federal government, ran COVID-19 tests on 2,500 sputum samples being used for another study on the flu virus. She found the first community-acquired case in a 17-year-old asymptomatic boy who was about to return to high school in Renton, Washington. The school was closed immediately after the information was verified.
By March 9, 11 days ago, there were 172 confirmed cases in Seattle and an alarming 22 deaths due to an outbreak in a skilled nursing facility in nearby Kirkland. On that day, Dean Paul Ramsey, MD, and the leadership of UW Medicine decided to cancel all work-related travel from university employees. Three days later, on March 12, UW Medicine made the decision to cancel all elective surgeries. On that day, there were 387 confirmed cases—despite minimal testing—and 30 deaths in the Seattle metropolitan area. Our hospital began to conserve masks, eliminate medical students and nonessential observers from using surgical masks to observe our cases.
As chief and associate chief of the division of vascular surgery at the University of Washington, we immediately made the decision to continue to offer surgery to abdominal aortic aneurysm (AAA) patients with diameters over 5.5cm, dialysis access and surgery for critical limb-threatening ischemia (CLTI) with a potential for limb loss. That decision quickly changed. On Sunday, March 15, when the case count was by now 642 cases and 40 deaths, we made the decision to call two friends in Italy, a country hard-hit by COVID-19 and in a state of lockdown and panic. Pierantonio Rimoldi, MD, and Germano Melissano, MD, based in Milan in the country’s north, gave us the terrifying news. Their healthcare system was completely overrun. These are the notes we took away from that phone call:
- 90% of the workload in all hospitals is related to COVID-19. The remaining 10% involves urgent/emergent patients. He carried out a ruptured AAA yesterday (March 19)
- Every intensive care unit (ICU) is filled with COVID-19 patients
- They have cancelled all surgeries except true emergency cases—they do not carry out elective AAA, CLTI patients or dialysis patients
- Everyone is isolated at home. The only places people are allowed to go are local pharmacies or food markets. If caught on the street without permission papers, they receive a large fine or three months in jail
- The Italian doctors say the only way to control COVID-19 is for people to stay home
- Their very first case—patient zero—was Feb. 20, some 24 days ago. Our first reported case in the U.S. was Jan. 21, and first death Feb. 29
- They said they do not have enough ventilators for all who require them. We asked what their triage criteria were:
- Age 80 and older—do not resuscitate (DNR)
- Age 70 to 80—if there are any significant comorbidities (congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, diabetes): DNR. For all others, a decision is made on a case-by-case basis
- All ventilators are reserved for people who have a strong chance of survival
- Almost all deaths are among the elderly
- They said surgeons do nothing except urgent or emergent cases. They are not being utilized in ICUs or wards because they simply get in the way. It’s like a pediatrician volunteering to come scrub-in on a case to “help”—they would just get in the way outside their area of expertise
These represent frightening statistics, altering our mentality completely. We immediately implemented the following changes to our service line:
- Cancelling all elective cases, including the ones listed above. Our patients fall into the category of high risk when contracting COVID-19. So exposing them and using up resources was not the right thing to do
- We will perform only emergent cases. Cases performed over the weekend were a ruptured AAA and a gunshot wound to a carotid artery
- Cancelling clinic to avoid exposure of our patients, staff and surgeons to COVID-19. If we are exposed and need to quarantine for two weeks, that could quickly decimate a vascular service
- Restructuring our faculty and residents such that one attending surgeon and resident will cover for a week at a time, with back-up as required for those that contract or are exposed to COVID-19—as well as the potential for multiple operations at the same time
- Eliminating any unnecessary time in the hospital. We have a daily Zoom morning report. Our weekly division conference, monthly faculty meeting and resident conference are also staged via Zoom
- Understanding our role in preserving the “3Ss,” as they say here at UW (staff, space and stuff). The projections at our hospital for the peak in three weeks’ time is sobering—potentially close to 1,000 inpatients in our system. We would imagine this is the same in other cities
- Preparing our residents to understand that some may be called to assist in ICU roles if our medical colleagues require the help
- Accepting that this is a crisis and truly understand what an emergent case is. We have never crashed a patient from clinic to the operating room. So any patient who is seen in the clinic is not an emergent case
- We may have patients who will rupture their AAA or suffer an amputation. We need to accept that today’s mentality is not the same as a week ago—and certainly not a month ago
Figure 1
As of the time of writing, here in Washington state we have 1,376 confirmed cases and 74 deaths, which we believe is just the tip of the iceberg. We expect our hospitals to experience a surge in COVID-19 patients by April 9 (see Figure 1). As two vascular surgeons with extensive combat military experience and experience working in resource-constrained environments, we desperately plead with all service chiefs across the United States to act this minute in order to conserve our resources and save lives. Don’t sit on your hands.
Benjamin W. Starnes, MD, is professor and chief—and Niten Singh, MD, is professor and associate chief—in the division of vascular surgery at the University of Washington, Seattle.
CHRONOLOGICAL Age is irrelevant. Consider cerebral competence as well as renal, cardiovascular and hepatic factors as well .
Thanks Dr. Starnes and Dr. Singh. This is really eye opening. We appreciate that you can share this with the community.
This is tragic and eye opening news. The ne thing I didn’t see mentioned was those people needing chemotherapy desperately. Where are they in this spectrum
Please define the Cease and Desist? Was this the IRB?
Dr. Starnes and Singh,
Thank you for taking the lead on this and providing us with the clarity and guidance that we need right now to act quickly.
Thank you Ben and Niten! As always the leadership you have displayed will be instrumental in saving people’s lives. Please stay safe and thank you for writing such a concise and impactful statement. As the Chair of Surgery here in San Antonio, I plan to share with my hospital leadership and all my staff surgeon in the Department of Surgery. We too have implemented these plans as of Monday, 16 March…but other hospitals in our organization have not…so I will share among those ranks. Thanks for all you continue to do!! My best to you and your families – stay safe!
Kate Markell
Ben, Well done. Please circulate this widely as all of our colleagues aree not there yet. Stay afe and well. Regards Rick Pearl
Can anybody suggest a website that I can access from my LG-6 cellphone providing truly “up-to-date” currently reported numbers “by state” AND “U.S. totals” including confirmed cases and dates?
I am thinking of something like those Population Counters.
Thank you.
M.E. – Retired Educator from Idaho
Thank you. Thank you so very much!
Ben & Niten: Thank you for providing this essential though sobering information. Although not providing primary care to the patients in the ICU, as a vascular surgeon also with extensive combat military experience, I believe we can provide valuable guidance. The mortality in the CORVID-19 patients is primarily due to ARDS for which conservative fluid management with a negative balance of 0.5 to 1.0 L qd is currently recommended. But this may not be sufficiently aggressive to prevent mortality. In Viet Nam from 68-69 we found that it was necessary to severely reduce IV fluids to DW KVO and use Lasix 20-40 mgm prn to increase urine output to 4-5L qd. On such, pulmonary compliance and blood gases greatly improve, the C-Ray clears, and the casualties survived. The same occurred with management of casualties from the Middle East we cared for in Landstuhl as part of the SVS volunteer program. These measures could reduce the mortality and the number and time of use of ventilators. Additional information is provided in a reply I placed in the SVS Connect Forum. Also, I am 88 but still functioning to some degree and would hope not to be triaged out.
Although not directly caring for severe COVID-19 patients in the ICU, vascular surgeons, particularly with extensive combat military experience as I have also had, can offer valuable guidance. The primary cause of mortality is ARDS and although the present recommendation for such cases is “conservative” fluid management with a negative balance of up to 1 L qd, we found in Vietnam in 68-69 that IV fluid had to be lowered to DW KVO & 20-40 mgm of Lasix given to correct compliance, blood gases, and clear the C-Xray with a negative fluid balance of 4-5 L qd to avoid mortality. I found the same occurred in caring for casualties from the Middle East more recently in Landstuhl as part of the SVS volunteer program. This can lower the mortality and the number and time of usage of ventilators.
Thank you for this article.
Whatever is being done in the hospitals is being rendered completely ineffective by the actions of people outside the hospital. Although there are stay at home orders in several states now, despite that, many continue to aggregate and be defiant. We need strict penalties in place as well for people violating the stay at home orders.
Thank you Ben and Niten for taking a leadership role and providing timely guidance
Although all of us in the Puget Sound area are at the nation’s epicenter for Covid 19, this pandemic is spreading rapidly and ALL departments need to take note and be proactive. We need to conserve resources and change our way of thinking of how we care for patient’s. Telemedicine is something we can offer our patients and maintain social distancing. Stopping all elective procedures to minimize exposure to our staff and patients as well as conserving resources and getting involved and partnering with our administrators who will depend on our clinical expertise to navigate through these uncertain times. We are all in this together and we will all get though this together as long as we remain thoughtful, pay attention to the recommendations from the experts, and take away the lesson learned from our colleagues in Italy.
Thank you Ben and Niten for the timely article. It has been interesting to see the variation in response from various institutions and even our colleagues. We have limited our elective surgeries and try to move most if not all visits to phone or e-visits with moderate success. I believe some guidelines from SVS could be helpful to have an uniform response in the vascular surgery community.
they forgot to add that their office staff was not informed about this problem and were left behind