Among member postings to the ACLP COVID-19 listserv is a diary from a global epidemic hotspot. It has attracted heartfelt gratitude from members—some of whom are quoted in the text below. The writer is Damir Huremović, MD, MPP, FAPA, FACLP, Department of Psychiatry, North Shore University Hospital (Northwell Health)—a health care behemoth with 23 hospitals in Metro New York.
DIARY ONE
‘We will Ring a Chime Every Time a Recovered COVID Patient is Being Discharged’
‘I can’t wait to start getting annoyed by that ring in coming days’
Diary entry: Early April 2020
Two weeks ago, we had nearly 300 empty beds (out of 800+) preparing for the surge. All patients who could have possibly been discharged were discharged, all elective procedures canceled. We are now at capacity and filling into our backup areas. We have around 600 COVID-19 cases, about one in five of them are in ICUs, and we are admitting at full force. Our non-COVID areas have dwindled down to four-and-a-half units and we have now started expanding into auxiliary space—our auditorium, our library, our conference rooms…
We are not without resources, so we deployed a mobile hospital we acquired a while ago and may be looking to expand it. We started sending patients to our on-campus rehab/nursing home building and, if the need be, will use our research institute next. Engineering teams are doing a marvelous job of re-purposing non-medical areas and fitting them for patient care. We are running low on ventilators. Our director of critical care hacked BiPAP machines to work as ventilators, our research institute is 3D printing the parts for the hack.
System-wide, the number of COVID patients Northwell hospitals care for is about 3,000. The peak demand is expected in about a week, perhaps sooner; the crest will likely last for two weeks or thereabouts. Men tend to be admitted more than women (about 57 to 43 percent ratio); M to F ratio in the ICUs is about 2:1. Our mortality rate is comparable to similar centers in similar situations.
We are developing guidelines and algorithms for better care which include earlier, more aggressive ventilation (patients tend to crash suddenly, with little warning signs). Renal failure appears to be a bad prognostic sign. We are developing a stochastic AI model for outcome prediction at the time of admission, which will play into the life-saving treatment guidelines used by our system.
Consults have gone down and are still down, for now. Use the time at the very outset to prepare. We have been fortunate to maintain our ‘regular coverage’ schedule, but have several backup plans on how to reorganize if we have to. Our sister-team at LIJ has been hit hard, with two members out with COVID (thankfully, mild symptoms), but they manage somehow. Our residents are being redeployed to join the medicine team; now they are asking for volunteers among Psychiatry attendings. Students were sent homes weeks ago, with all educational activities shelved. They are petitioning to come back though, as volunteers; not sure if that will be allowed. We are getting our first COVID-recovered team member in the coming days. Try to make plans for such situations as well.
“Thank you for your moving post. We are preparing for the surge, but we’re a few weeks behind you. Your writing in the midst of chaos helps us prepare.”
Consults are mostly for managing agitation in delirium, very few consults for delirium itself. I would suspect a significant number of delirium cases based on the sheer volume seen on regular hospital and IC units and then some, based on the implicated IL-6 involvement in the distress response in critical patients (which, we know, is also involved in the delirium cascade). I ascribe this to the use of Precedex and the overall isolation of the patients. Isolation will be an overarching theme. Breaking the isolation will be your mission impossible, should you choose to accept it. The next considerable group of consults we see are otherwise relatively stable COVID patients who are frantic about the possibility of an imminent demise. Haldol works fairly well for delirium and agitation; we are still in search of a go-to agent for anxiety and apprehension; we are looking at several 5-HT2 antagonists, rather than the benzo route. All suggestions in this regard are welcome.
We see and hear everything in between, just with the COVID twist—an autistic patient, a patient in alcohol withdrawal, a suicidal patient, a couple of heart transplant cases. We see COVID+ patients remotely; also extend the same caution to our immunocompromised patients—no need to risk exposing them.
“Thank you so much for that thorough and honest account of life at your hospital. The ingenuity and agility you described are inspiring and, I suspect, qualities we will need to aspire to in the weeks ahead.”
I can see by your questions and concerns approximately where you may be on the curve of this tsunami. Go ahead, draft your protocols. Finalize them. Print them. Shred them. Everything you know about your work goes out the window and you have to get creative with every new case. Use whatever you can—video links, tablets, smartphones, built-in AV equipment, patients’ hospital room phones, faxes, Morse code… whatever works for a particular case at that time is the best modality. We have collected money amongst ourselves and bought a tablet to hand out to patients when there is nothing else. It was the last one in the store. We have a proprietary system in the ED with telecarts. It works well there, because the ED has been using it for years for overnight coverage. It does not work on the floors. So, we use doxy.me, FaceTime (and I don’t even have an iPhone), and whatever else will work in that moment. Still, no matter how sophisticated system you may have (or lack), you will always be limited by two variables:
Different units develop different attitudes among staff within hours of being designated as a COVID unit. Some are friendly and cooperative, some… whatever is at the other end. I dread the dejection on the faces of my colleagues and in the tone of their voices when I tell them I am not entering the patient’s room. We are colleagues. We are equal. We get to stay behind, they get to enter that room. Great set-up for liaison work. Our hospital limited clinician encounter with COVID patients to one per day. No more resident rounding, then the attending rounding with the team, then the consultants… One. That’s it. The best approach is therefore to ask when will someone from the team be entering the patient’s room, and then ask them to help establish that link. Some will help with patients’ phones, some will volunteer their own phone, some will accept to hand over your piece of equipment to the patient. Use whatever they feel comfortable with; be appreciative of their favors and grateful for their work. Be prepared to wait. The clock ticks. Frustration abounds. Try to work with other consultants and hospital leadership to see how communication issue can be addressed. Administration may develop different solutions for different units.
“Thank you for keeping a journal of not only your experiences but also the creative and innovative approaches that you are using to deal with this overwhelming and terrifying epidemic in the context of incredibly inadequate resources. It is clear that C-L Psychiatry gives us the background to work under the most trying of circumstances.”
We started doing Balint groups for our colleagues. In an ordinary Balint group, when a clinician presents a case, it is to understand and enhance their relation with that patient for future benefit. In our ‘Balint group’, the patient invariably dies. It is very awkward to do such groups with your colleagues through a screen. It is uncomfortable. Surreal. Virtual silence is not a therapeutic tool. But we grind through it somehow. We did some work with the ED (preoccupied with their workflow), social workers (preoccupied with how to cheer up teams on their units), hospitalists (preoccupied with patients suddenly dying). They say it helps. I am not so sure. But it sure does help me. It’s a new routine, but a routine that keeps me sane.
I cringe when I hear an overhead pager: “Anesthesia, stat…” Ten, dozen times a day. It will likely remain a trigger for the rest of my life. We all cringe. To do something about it, we are going to ring a chime every time a recovered COVID patient is being discharged from the hospital. I can’t wait to start getting annoyed by that ring in the coming days. We discharge a lot, you know.
Stay positive. Try to take care of yourselves, your families, your teams, your colleagues. Let them take care of you. Have confidence in your skills, instincts, knowledge. You’ve got this.
DIARY TWO
Staying Afloat
‘The high tide has come and, by now, somewhat receded, but the water is still high’
Diary entry: Mid-April 2020
Past fortnight was filled with trepidation and attempts to attain mastery at… something. Staying afloat, mostly. Keeping the service going while trying to stay safe. The high tide has come and, by now, somewhat receded, but the water is still high. NSUH is at the border of Nassau with Queens, the third and the first county in the country, respectively, with the number of registered COVID-19 cases. It was unreal. Still is. Uncanny. Unheimlich.
Judging by the numbers, we are managing well. We have managed to squeeze by without putting every single ventilator, every single makeshift bed to use. There were no patients in the hallways, there was no chaos, no panic, no sense of despair. Our number of COVID patients finally dipped to just below 600 after hitting 700 for 10 days. We are folding down some extra space, as it is no longer needed. We may finally establish one building (the smallest one out of five) as COVID-free. We may get our perinatal care back where it belongs, not at some pavilion up the hill, where new mothers are housed like soldiers in the barracks, away from their babies. Our auditorium still houses COVID-patients, though.
The hospital has gotten better at doing this. Much quicker determination in the ED, less tentative, more confident discharges, tweaked algorithms, more aggressive intubation when indicated. The census of our regular floor patients is going down, we are tackling the challenge of accepting the most difficult patients from other hospitals, thus expanding our ICU capacity. We are using HCQ, tocilizumab, sarilumab, anakinra, plasma… We have almost 200 patients enrolled in research protocols. We have discharged our 1,000th COVID patient tonight. A lot of annoying chimes that accompany every discharge. We still struggle with getting patients off ventilators, though. Last week was particularly bad. We started with 22 weans up till then, the number went up to 25 by mid-week, only to go back to 22 on Thursday. We managed to eke out a small victory by the week’s end at 26. Now we are over 60. But we have about 160 patients on ventilators at any given moment; you do the maths. Admissions are still more men than women (60 to 40 percent) and even more so in the ICUs (70 percent males). Our personnel loss rate due to COVID (temporary, of course) is below 3 percent.
My service still does everything and anything that will get the job done. Weekends are FaceTime days. All weekend nurses and floor staff going into the rooms somehow prefer FaceTime on the floor tablets to any other method. So we Facetime. Weekdays, we have a telepresenter pushing one of our ED telecarts through the floors and taking us to see patients. It still sucks. It will suck for a while. Connection drops. Your screen freezes. The patient’s screen freezes. So we hybridize sometimes. A little bit of chat over the phone, then you gown up and pop in to wrap up the chat. We ought to patent those. Makes it more personal. But not by much. When you’re all dressed up like a Teletubby (Laa-Laa, in my case, as our suits are yellow), with goggles, visors, and what have you, you don’t exactly come across as an empathetic therapist, but merely serve as a stark reminder of patient’s newly acquired social status. COVID-positive. Isolated. On the other side. So, don’t feel too guilty for not sitting down with a patient for a chat. Those days are gone. For now.
“Your accounts are harrowing and moving. You bring alive the unique role that C-L Psychiatry plays in the medical world in ways that are rarely visible.”
Patients are difficult to treat. They are really very ill. Or very scared. Sometimes both. ICU teams tell me that many of them require ‘unreal’ doses of medications during the ICU stay to keep sedated and ventilated. That translates into higher doses required for agitation once extubated. But there is little space to maneuver—hearts teetering on the verge of arrhythmia, livers blown, kidneys shut. We still don’t get called for a number of patients with delirium I would expect to see in this situation. We may not ever get called due to enormity of the workload placed on the primary teams. I developed a flowchart to help ACPs and dermatologists drafted into this with the basics of delirium and agitation management. Not sure it will be good for business; I sure do hope it will be good for the patients.
Now, we have a new normal. A normal where we put everything aside so we can deal with this invisible adversary. So we pay a steep price. No transplants. No elective procedures. No procedures at all, unless they are absolutely necessary. Barely any ambulatory care. People stay at homes. People die at homes. Around here, just like in the City, if a patient codes at home and cannot be resuscitated, that is the end of the line. They are not taken to a hospital. We have lost several inpatient Psychiatric departments across the system to make room for COVID patients. Beds are harder to book. We have been operating several COVID-19 inpatient units for weeks now. I test every patient I admit. And it still finds its way into non-COVID units. Once detected there is a mad rush to transfer a newly-discovered COVID case to a COVID unit. Sanitize, repeat. My resident is still on loan to Medicine, we don’t know if and when she is coming back. How will she cope?
Our fellow returned to the service. She is supposedly now ‘COVID-resistant’. We are all still trying to wrap our heads around it. What does it mean? What PPE ought she don? Who is she protecting; from whom? What ‘side’ is she on now? How did we even get to this question of ‘sides’? Like in every contagion, psychologically, there are sides. At this point, we at least have ample PPE for the level of utilization we need. Yet we still don’t know where the little deadly particles are and struggle to optimize our protection from them. We are basically fighting a 21st century pandemic with the 19th century tools. See how that is working out for us?
I still run groups. They are difficult to implement. They are awkward. But some people still show up. ED, anesthesiologists, hospitalists. Not sure if it’s any good, but it feels like something I should do. Social workers really like it. I told them we are not stopping these virtual groups until we meet in person. Then we will be done. I sneak into the units sometimes. I hang out with the team there. ED, ICUs. They like to talk—a lot. There’s your group. Once you do it, you’ll know what I mean. The most honorable way to keep that -Liaison attached to your title. And I know there are risks. “But this is not exactly Ebola,” I tell myself.
“This is an extremely moving and special account of the C-L role on the frontline of this pandemic. You have documented clearly and eloquently the interface of Psychiatry and Medicine at the height of a response to an unprecedented disaster. Thank you for the courage and care you exemplify.”
Yesterday, I ran a group for respiratory therapists. A real, eight-person group in their huddle room. They would not come to Zoom, so we went to them. It was devastating. They put so much effort, so much hope, so much faith into their work only to have all of that shattered. Defeated, impotent, hopeless is how they go home at the end of the day. Seems as if their basic belief in humanity is brought into question. Caring for people who will die, no matter what you do, who will die alone, with no comfort, separated from their families, isolated from their dignity. And who will die in droves. That is an onerous burden to take home. I was at a loss for words. And yet, they were looking for words of hope, of encouragement. From me. They told me so. I stammered. I am not quite sure that anything that came out of my mouth at that moment made any sense, but we agreed to meet next week. I hope they come.
That is our life right now. It will get better. That I know, but I don’t know by how much. We cannot keep our life on freeze for too long. Tumors still grow, people still suffer from other innumerable diseases that kept our hospitals fully occupied before all this happened. We will have to get back to that soon. But at least for a while, it will not be ‘life AFTER COVID’, it will be ‘life WITH COVID.’ We will have to learn to manage this like people learn to live with and manage their diabetes or their renal failure.
We get a lot of support from the community. They really want to help and show their appreciation. It feels good to be recognized. It is inspiring, even. I get a lot of support from you, guys. Some of you I know very well, some not at all, but I appreciate it all the same. I hope and pray that you don’t get where we in Metro NY are, but if you do, reach out; I will do my best to help. Otherwise, this thing has become so asynchronous and amorphous that each one of us will end up having such a unique experience of it that my advice is practically useless.
Regardless of how long this takes, I know we will get there. I just don’t know where that new ‘there’ will be. Until then, stay positive. Or stay negative. Or… stay however you prefer, just keep safe.