March 28, 2020
From the Front Lines…

A friend who is a doctor in a New York City hospital sends this:

Things here are changing daily. The number of virus patients has increased rapidly, tripling in a day. We have twice as many doctors and nurses infected as patients. This is because we are at the beginning, and doctors and nurses have more social contacts than our generally more isolated patients, and possibly because of reinfection, which is still controversial but seems more likely as a possibility now than it did last week. But also it is because we do not have enough masks and equipment.

The number of people who go into a room has been strictly limited but still people must go in. The hospital has now issued guidelines for reusing masks. This is more or less like being told that we should reuse needles, shocking for anyone trained in the modern era, contrary to the basic rules we are drilled on every year as part of the hospital licensing requirement. We think this is “better than nothing,” but we do not know. What we are doing now would never be the answer on any licensing examination. People are doing the best they can.

The pneumonia caused by this virus is especially severe. While even most cancer patients will survive, those who are severely ill have to be kept on a ventilator for a long period of time -- it seems to be about ten days usually -- before either improving or entering a brief final deterioration. They often must be kept in the prone position during this time, which is much more physiologically taxing and of course psychologically distressing.

The virus seems to be associated with a particularly severe form of agitated delirium, worse than what we might see occasionally with other pneumonias. Some of the most important treatments for agitated delirium have potentially dangerous interactions with medications for the virus, which makes management more challenging. Delirium is often but not always managed by psychiatric consultants so this may put a strain on our department though it has not yet. Across the street at New York Hospital the psychiatric residents have been redeployed to the ICU not as consultants but as regular ICU doctors because of the growing need and the number of doctors and nurses who are out owing to infection.

This type of redeployment is not as likely to happen in our hospital because we have been designated as the hospital to receive cancer patients who must be moved from other hospitals to make room for virus patients. We are likely to continue with a smaller overall percentage and number of virus patients. It is a hard thing though to be hospitalized with cancer and to be moved to an unfamiliar hospital away from your oncologist. It is especially tough because visitors are no longer allowed in the hospital with the exception of those visiting pediatric patients and patients actively dying. One virus patient committed suicide yesterday at another hospital, though I do not think this is public. We do not know the circumstances but certainly one way or another the prolonged isolation and limited staff contact are likely to have played a role.

Still, though, as I said to one of my Catholic patients, until we see four horsemen out the window, it is not Armageddon. Grocery stores and restaurants are delivering. The mail is getting through. Apart from some consolidation of nearby branches and reduction in some hours, pharmacies are open. The power and the Internet have been reliable. (If I had money to invest I would look into Zoom, which has proven much more stable than other teleconferencing apps.)

Theoretically you need an ID with a special sticker and a letter from your “essential” organization in order to walk on the street (yes, we actually have to carry papers!), but in fact there are people outside walking and clearly not just going from home to their critical work. I do not know how to feel about this: on the one hand it is a violation and possibly demonstrates some lack of awareness; on the other, it is easy to maintain more than six feet of distance outside, and except in crowds, which have now vanished from the city, transmission out of doors should be very unlikely. Certainly we have seen the physical and emotional dangers of isolation. So people are doing their best, and eventually we will come out on the other side.

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Posted by Jerome Doolittle at March 28, 2020 02:22 PM
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