Copy
Intensive Care: On the Front Lines
April 13, 2020

The Power of Words

A message from the chair, Dr. Steve Abramson

Sometimes it’s best to let the words of others speak. Below we share messages of support from Residents at Brigham and Women's Hospital in Boston to our Residents.


Above: A Pulmonary/Critical Care fellow and Cardiology fellow work in perfect orchestration on a patient with ARDS and cardiogenic shock. (To respect confidentiality, no patient information is displayed in this picture)
 

Intensive Care: On the Front Lines

Doreen Addrizzo-Harris, MD, has witnessed her share of epidemics and disasters during her tenure at NYU Langone, from AIDS and Ebola, to September 11 and Hurricane Sandy. Still, as one of the key physicians managing staffing of the ICUs across the institution and herself caring for COVID-19 patients with underlying pulmonary disorders, Dr. Addrizzo-Harris says the current COVID-19 pandemic is unlike anything she has previously seen.

An unprecedented number of patients have been admitted to our hospitals, leading to rapid expansions in space and workforce. And with the disease spreading so quickly, one of the biggest challenges with COVID-19 is that there are still so many unknowns. In some of the most serious cases, such as those in the ICU, there’s also precious little time to figure out the best course of treatment before a critically ill patient succumbs to the disease. It’s a unique situation, says Dr. Addrizzo-Harris, different from the slower deaths of AIDS patients, which allowed physicians to develop bonds with those in their care, or the aftermath of Hurricane Sandy, in which there were enormous logistical problems, including the mass evacuation of patients, but no fear of personal harm to the medical staff.

Despite these challenges, the crisis has brought out the best in everyone—and on every level, from senior leadership to support staff to those on the front lines. Physicians and nurses from all areas of NYU have stepped in to help where needed, and skilled fellows from other programs have joined the teams in the ICU, finding their footing and bonding with new colleagues quickly. The response to calls for help from outside the medical center has also been heartening: ambulatory physicians at all of our sites have volunteered to help on the inpatient side, previous fellows have returned to work alongside their former mentors, and several naval officers have joined the team at Bellevue Hospital. We have help from every Department and Division. “It’s pretty amazing, what we’re able to do,” says Dr. Addrizzo-Harris. “Everyone has stepped up to the challenge. Nurses and respiratory therapists have been among our biggest heroes. You never know what you’re thankful for until you have a disaster like this.”

Beyond the huge response to our ‘all hands on deck’ ethos, Dr. Addrizzo-Harris notes that there have been some major developments over the past few years that have ideally positioned NYU Langone’s hospitals to meet this crisis head on, including the opening of the Kimmel Pavilion; the hiring of Mark Mulligan, MD, to lead our Division of Infectious Diseases and Immunology and the Vaccine Center; and the successful implementation of Epic and our telehealth program.

“We have so many resources between our 4 + hospitals—our brilliant faculty who are already looking into treatments and cures, our innovative leadership at each hospital, and our energized, dedicated fellows and residents,” says Dr. Addrizzo-Harris. “We will get through this and look back one day to tell the story."


Back in the Hospital After 35 Years, and Other Stories from the Covid-19 Front Lines

Across our campuses, clinical staff are dusting off skill sets and stepping into unexpected roles to support colleagues caring for Covid-19 patients. Gastroenterology chief Mark Pochapin, MD, picked up a camera and captured two colleagues who are wearing new hats, in the video above. You can also read about Caren F. Behar, MD, internist and medical director of the Joan H. Tisch Center for Women's Health, who volunteered to staff hospital units during the coronavirus pandemic. Click here or on the image above to watch the video.

NYU Langone Patient on the Road to Recovery

Read an article by an NYU Langone patient, David Lat, in The Washington Post"I spent six days on a ventilator with covid-19. It saved me, but my life is not the same." and watch a video of Lat, on TODAY


The Historian Is In: Influenza of 1918-1919

David Oshinsky, PhD
Professor of History and Medicine
Director, Division of Medical Humanities

 

The history of past epidemics can provide important perspective on the current COVID pandemic. In each issue of the newsletter, we will revisit a past epidemic, from Yellow Fever to Ebola.

~~~

At the very height of World War I, a pandemic of biblical proportions swept the globe. Erroneously called the “Spanish Flu,” its origin is controversial even today, with historians tracing it to China, to an army camp in Kansas, and to the battlefields of France. Before it ended, the so-called Great Influenza would kill more people in a shorter time than any event in human history, with some 50-to-80 million deaths in less than a year. Though figures vary, it’s estimated that one American in four contracted the disease and that 700,000 died. The numbers are so staggering that average life expectancy in the United States dropped twelve full years before the virus burned itself out.

Influenza typically preys upon those with the most fragile immune systems, especially the aged. COVID-19 is a case in point. But this outbreak was different: it struck hardest among those in their 20s and 30s. Some blamed the war—the overcrowding in army camps and on troop ships, the miserable conditions of combat. The problem, however, is that the Great Influenza played no favorites in this age group; women and male civilians were equally at risk. The most intriguing theory relates to a process known as “cytokine storm,” in which a vigorous immune system responds so forcefully to unfamiliar microbes as to literally drown the lungs in gooey phlegm, dead cells, and assorted debris. Indeed, most of the victims in 1918 died from bacterial pneumonia, not from the flu.

By October, the pandemic had felled thousands of New Yorkers. As it spread, the City Health Department banned spitting in public as well as “promiscuous coughing and sneezing.” It also sent nurses throughout the five boroughs to visit the sick—there was no mandatory quarantine—and to staff the armories set up as auxiliary hospitals. To prevent crowding on the subways, the city mandated staggered working hours and forced theaters to cut their ticket sales in half. Public schools remained open, but only because the health commissioner thought the classrooms to be safer for children than the slums where so many of them lived. Public libraries stopped lending books, gauze face masks became regular attire, and people stopped shaking hands.

That October, Bellevue saw more admissions than at any time in its history. There was little to be done beyond providing aspirin, whiskey, and words of comfort. Patients weren’t the only casualties. So many nurses and doctors took sick that city officials thought seriously about limiting new admissions. They decided against it; no one would be turned away, though some patients wound up sharing a bed or sleeping on the floor. “It got to the point where I would see them only twice,” a medical resident recalled. “Once when they came in and again when I signed their death certificate.”

Meanwhile, work proceeded on a flu vaccine led by two distinguished NYU Medical School researchers—Hermann Biggs and William Hallock Park—who had recently brought the lifesaving diphtheria toxin to the United States. The results, however, were discouraging. Their laboratory couldn’t isolate the responsible pathogen, an impossible task at that time given the mysteries of the endlessly mutating influenza virus. Though the vaccine failed badly, the trials did alert Biggs and Park to the fact that the strains of pneumococcus circulating in the pandemic had produced lung infections deadlier than anything they’d seen before.

An estimated 30,000 New Yorkers perished in the Great Influenza. Yet the city had a significantly lower death rate than the metropolises north and south—Boston and Philadelphia—due to the active involvement of its medical and public health communities. Today, New York faces its greatest medical crisis since the Fall of 1918. As Ground Zero for another deadly virus, the city calls once again upon the courage, resilience, and professionalism of those trained to serve and to heal. It’s a tradition that goes back centuries, showing New York at its finest.


Uncharted Territory: A Medical Student on Distance Learning

Jamie Fried
MS2, NYU Grossman School of Medicine

Med students are planners. Getting into NYU takes months if not years of advanced preparation, so our paths up to this point haven’t exactly equipped us to “just roll with it.” Two weeks from now, when our current ad-hoc remote electives end, MS2s have no idea what we’ll be doing, no idea where we’ll need to be, and no sense of what will be expected of us. The uncertainty is hard, especially when mingled with the guilt, envy and, frankly, relief that comes from being not quite ready to staff the front lines.

We were pulled out of clerkships one week before the end of the rotation, shelf exams were called off, and grades were switched to pass/fail. MS2 reactions varied. Students finishing 12 weeks of internal medicine greeted the cancellation of exams with a wide range of emotions – they were temporarily off the hook but looking back at 11 weeks of at least partially wasted effort. A friend, who confessed that he hated neuro, was glad it ended early. A future surgeon friend was counting on a good grade during her surgery rotation and felt slighted walking away with a pass.

In what must be record time, clerkship directors threw together four-week web-based extensions of each rotation, so our education could continue without pause. Compared to hospital shifts, these are, according to one friend, “very chill,” and I’ve heard several students in other departments complain that they wish their electives were more pandemic-focused, like the internal medicine department’s. My experience with remote learning has been smooth and easy, but I’m lucky enough to be taking a medical humanities elective that has been around for a while, unlike the improvised stopgaps that were built from scratch in a hurry. It’s been nice calling into seminar in PJs, taking midday runs, and staying up late reading instead of studying, but it’s definitely easier to be distracted during a Webex class than it is on the wards, and a choppy internet connection can ruin an otherwise good discussion.

My classmates and I have taken advantage of the extra free time to dive headlong into volunteering efforts. While I’ve been making calls for the Family Connect program and eyeing the early graduating 4th years with alternating jealousy and relief, the entire MS2 class is busy making face shields, phone calls, PPE pickups, care packages, Instagram PSAs, and really doing whatever we can to feel helpful. It’s been inspiring seeing my classmates step up, turning our pent-up anxiety towards fighting COVID-19 however we are able. None of us know what’s next in our education, but I suspect that this experience is contributing to that education in ways, some of them profound, that we’ll only discover later.


Fear and Hope in the Era of the Modern Plague

Jose U. Scher, MD
Associate Professor, Division of Rheumatology
Director, Arthritis Clinic and Psoriatic Arthritis Center
Director, Microbiome Center for Rheumatology and Autoimmunity (MiCRA)

 

A mantle of darkness has descended upon us, profoundly shaking our lives. For half a century, we have managed to convince ourselves that advances in biotech and an ever-expanding access to devices and simulated platforms would take us to an incontrovertibly better place. That by bending the rules of time and space we would be able to seamlessly trade the real for the virtual. The problem for this Brave New World, however, is that we have evolved to communicate in a manner that transcends the visual and the spoken. We need to be close. Our relationships require a level of intimacy that, for this peculiar moment in time, has all but vanished. We offer trust with a handshake, generate comfort with a smile, and illuminate someone’s desperate moments with a simple hug. But what was once natural now seems distant and dangerous.

Like all of you during the past several weeks, I have witnessed the unintended consequences of abdicating a piece of humanity in ways both trivial and vast. My children could not share laughter with their friends during their birthdays (try to blow out candles over Skype); there were moments when a fellow or a colleague cried on the phone and all I could mumble was, “it is going to be alright,” even when I knew that the only consolation and true empathic gesture would have required not just my words, but my arms and eyes; and then there was a colleague who could not be by her father’s side before he passed away. And during her third day of mourning, she was then told that her aunt had also succumbed to the virus.

This plague, like the ones before, has brought fear, anxiety, and a sense of helplessness. There is fear of the unknown, fear of what the future may hold, and fear of failing the moral test that is required to meet the challenge before us. But above all, there is the fear of death; the one battle that we know, with absolute certainty, cannot be won.

And yet, we obstinately refuse to relinquish hope. We seize on our existential fear of mortality and transform it into a fight for life. It is a gradual but inevitable metamorphosis of despair into integrity. And just like that, we realize that plagues are rather about courage and bravery and character. I’ve witnessed the Robs, the Eileens, the Peters and Pamelas of the world who enlisted first for the battle, unconditionally, no questions asked. And the Kristens amongst us, who had left practice but was compelled to return because her inner voice told her it was her moral duty to help heal the sick. There were the Rebeccas and the Rochelles and the Dis, who have gotten sick but immediately after posting their test results (with pride!) continued to work on their projects and caring for patients in need. And there was the other Rebecca, who has done all of the above (and more) with grace and composure. I’ve seen the most remarkable group of fellows, residents, students, and nurses who have shown camaraderie, dedication and valor each step of the way. And then there was each one of you, who made the impossible possible, whether through adapting to new technologies in a matter of days, coalescing around intellectual endeavors to help understand this challenge better, and by extending a hand to your colleagues or by offering the comfort of your voice to friends, family and countless patients. We should therefore find solace and assurance that the future of our collective endeavor is bright.

This is the time of the year when many of us are commemorating resurrection or a journey from slavery to freedom. And for those who avoid deities altogether, this moment is devoted to welcoming the cycle of life that spring announces. But these are no ordinary times, for I know that we will go through this experience with intense pain, irreparable loss, and enduring grief.

However, as Camus' Dr. Rieux noted, “[very soon] our whole town will rush outside to celebrate a crowded minute, when the time of suffering had ended and the time of forgetting had not yet begun.”

Because in the end, we will have learned once again what the Plague really means. It's life, that’s all.

[This essay was edited for length. Read the full version here.]

COVID-19 Links

Department of Medicine intranet site
Department of Medicine COVID-19 blog

Inside Health (atNYULMC) home page, for daily posts and articles

Resources for Managing and Surviving the COVID-19 Crisis
(With thanks to Dr. Sandy Zabar and the DGIMCI team)

Covid-19: What You Need to Know - Information Hub

Share Your Creative Work

If you are interested in submitting an essay, poem, or artwork related to the COVID-19 pandemic, we'd love to take a look. We will feature selected work in upcoming issues. Email your submissions to DOMCommunications@nyulangone.org

Recommended Reading: Books by Nurses

 

TAKING TURNS: STORIES FROM HIV/AIDS CARE UNIT 371, MK Czerwiec
In this graphic memoir, Czerwiec chronicles her first nursing job on a dedicated HIV/AIDS ward, giving readers both an historical snapshot of that time and an intimate look into the experiences of patients and caregivers during moments of tragedy and hope. Library Journal called it “Cathartic and clinical, often simultaneously.”

I WASN'T STRONG LIKE THIS WHEN I STARTED OUT: TRUE STORIES OF BECOMING A NURSE, Edited by Lee Gutkind
This collection of essays highlights diverse voices from the world of nursing, from nurses-in-training to those with decades of experience. With honesty and compassion, they relate tales ranging from being present at their first birth, to caring for those in nursing homes, to being the sole attendee at a funeral for a patient.

EBOLA SAFARI: ONE NURSE'S EXPERIENCE INSIDE THE SIERRA LEONE EPIDEMIC, Richard Mertens
This book recounts the author’s experience as a nurse volunteer during the West Africa Ebola virus outbreak in Sierra Leone, dealing not only with a deadly virus, but with challenges created by poor infrastructure and bureaucracy.

NOTES ON NURSING: WHAT IT IS AND WHAT IT IS NOT, Florence Nightingale
Published in 1859, Nightingale’s slim book contains many ideas that were groundbreaking at that time, including an emphasis on hygiene, communication skills, and the value of careful observation. An important historical text, still relevant to modern nursing.


                              

© 2020 NYU Langone Health  |  550 First Avenue, New York, NY 10016
Copyright © 2020 NYU Langone Medical Center, All rights reserved.