It's early Monday morning on a very grim and rainy day in New York City. I have received several text messages already from Emergency Department and ICU doctors from across the city. "How many?" That's all we ask because I already know what they are referring to, the death count over the weekend.
Every day we lose more and more patients to this illness. For many of us, we have never seen anything like this before. "Four", I text back, "What about you?" "Eleven", replied one colleague causing a solemn lull in the exchange. We have now reached a point where we don't have to say how sorry we are to hear this terrible news. We don't have to say, "I hope you guys are doing okay", or, "If you need anything let me know". None of this needs to be said now because it is understood.
The SARS-COV2, also known as COVID-19, has devastated the city of New York like it has no other. New York City has had more cases and deaths than entire countries combined. A vast majority of those dying are also the most vulnerable. Elderly patients, nursing home residents, the poor, the destitute, and the chronically ill. I work in the largest public hospital system in North America. We provide care to these very patients. They arrive in droves, distressed, anxious, and scared. We must see them alone because their family members are unable to join them due to the virulence of the disease.
Many of them die alone either in our emergency rooms or intensive care units. For many, this virus seemed to have come out of nowhere. What started in a small provincial wet market in Wuhan - a place few had previously heard of - now devastates the most powerful city in the richest nation in the world. With all its checks and balances, with all its expert forewarnings, some might say we have been caught napping and wholly unprepared.
I will be one of the first to admit that I underestimated the severity and ferocity of this pathogen. As news began filtering from other hospitals around New York City, about a deadly form of flu, I just dismissed it as a minor outbreak of a common cold that would contain itself soon and deserved no further attention.
When some of my colleagues started wearing masks and gloves even while sitting at their computers I laughed and made fun of them. (In my defence, I did have some very good jokes about their appearance.)
Yet within two weeks, I experienced high fever, chills and body aches. I was stricken hard with COVID-19, a "cold" that could have killed me. My lack of preparation and attentiveness, combined with my cavalier approach to wearing personal protective equipment (PPE), could have ended my life. Despite how high the stakes were in the beginning many, including myself, did not appreciate the danger.
Thankfully, I was able to recuperate at home and return to work within only a few weeks. Unfortunately, many of my fellow healthcare workers were not so fortunate. This virus has ravaged our cities and our homes, our friends and families, and often we have felt helpless to stop it.
One of the biggest challenges in this whole process was timely access to PPE. In a matter of days, all hospitals faced critical shortage of masks, gowns, and shields. The demand was unyielding, overwhelming, and still growing; the supply, finite and strained. Every department in every hospital in the city was desperate to get these supplies for their staff, without which, taking care of patients would put them in harm's way. Even now, securing adequate stock of PPE continues to be an issue.
From an Emergency Medicine perspective, this virus presents its own challenges. Some patients are asymptomatic. Most experience coughs and colds, but the more severe patients arrive in respiratory distress due to severe pneumonia. These patients are coming in cyanotic blue - literally looking bluish - reflecting the lack of oxygen in their bloodstream. The Great Influenza Pandemic of 1918 was called the "Blue Death" as those patients, too, died of air hunger and oxygen starvation.
One of the tenets of Emergency Medicine is to protect and secure the airway and breathing of any patient in distress by placing them on a ventilator. In fact, conventional wisdom and early shared experiences emphasized providing ventilation to COVID-19 patients quickly. Yet this process, too, posed a health hazard to the very doctors and hospital staff performing this life-saving intervention. The process of bag mask ventilation, a precursor to placing the patients on ventilators, creates clouds of virus-rich droplets and disseminates them in the open environment. There are instances of doctors and staff members who, in spite of wearing PPE were exposed to these malignant mists and died weeks later as a result. The initial surge of sick patients saw hundreds of thousands being placed on ventilators. A lot of these patients ended up dying, which forced us to rethink the "Early Ventilation" strategy. As time passed, we learned from our own experience on how better to manage these patients. Some emergency rooms started using modalities to delay ventilation or avoid it altogether. We started "proning" patients, making them lie on their stomachs on the stretcher and placed them on specialized oxygen masks that delivered large volumes of air to the lungs. Decreased ventilations saw improved survival rates as well as reduced exposure to doctors and nurses. Presently, we believe this is the best strategy for managing COVID-19 patients; however, treatment plans continue to evolve.
The months of March and April saw patient volumes surge exponentially. In its unbridled virulence, this affliction consumed everything we could throw at it, like an implacable black hole. We ran out of stretchers and beds, of masks and gowns, and, finally, oxygen tanks and ventilators. Hospitals struggled to replenish resources and expand capacity, and yet demand always superseded supply.
This virus killed with impunity and didn't discriminate against the young or old, the sick or healthy. We saw more deaths in a week than we usually do in a year. The coroner's office sent refrigerated trucks to every hospital as morgues across the city ran out of space. Inside those trucks, bodies were stacked on shelves until overrun funeral homes could take them away. Photos of workers digging mass graves circulated online, a macabre reminder of the deadly grip our city was in. Those few weeks were some of the most trying and challenging in our living memory.
It was around the middle of April when we began to see some respite. Fewer patients were coming into our emergency rooms and those who did seemed to be doing better.
And that is where we sit today, on a sombre Monday. Things seem to be getting better, relatively speaking, but it is almost impossible to predict what lies ahead. Some states are relaxing social distancing measures, which were one of the main reasons the spread was controlled. Others have declined to comply with masks and isolation recommendations at all. And so our greatest fear now is that the relaxation of these practices and public perceptions could precipitate a second wave, possibly even more deadly and more cruel than the first, as happened during the "Blue Death" Great Influenza Pandemic of 1918. But these are conjectures and educated guesses. The truth is that we don't know what lies ahead, and accepting that reality is perhaps the greatest challenge of all.
(Dr. Rajnish Jaiswal is the Associate Chief of Emergency Medicine at Metropolitan Hospital Centre in New York City and Associate Professor at New York Medical College. He is also an actor, writer and comedian.)
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