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The Historian Is In: HIV/AIDS ~ The VA's "Fourth Mission" ~ Voices from the Front Lines
May 4, 2020

“Perhaps, the end of the beginning”

A message from the chair, Dr. Steve Abramson

In 1942, after the rout of Rommel’s forces in Egypt, following a series of British defeats, Winston Churchill delivered these famous words: "Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning." Unfortunately, we have achieved no great victory against COVID-19, but we have seen encouraging trends, including the decline of new cases in NYC and positive clinical results with Remdesivir. Vaccine trials have begun and there is reasonable hope that through science better therapeutics will emerge.
       Last week in a WebEx for House Staff, David Stern, Doug Bails, and Brian Bosworth, the chiefs of medicine at our Manhattan hospitals, along with Patrick Cocks our program director, reviewed the cumulative COVID-19 experience with a particular focus on the extraordinary contributions of our residents and fellows. Certain milestones were reached recently, with Tisch-Kimmel and Bellevue Hospital discharging the 1000th and 500th COVID patient, respectively. Underneath these milestones is the unprecedented commitment of our house officers, physicians, nurses, physicians’ assistants, and staff to the ever-expanding universe of COVID patients. We’ve seen devotion, personal courage and sadness that permeated each hour of every day. Throughout these weeks we also saw unparalleled teamwork across our hospitals and divisions, reflecting the professional values of every member of this department. I am extremely grateful to all of our trainees, faculty and staff who have come together during this crisis. And we are blessed by the extraordinary talent of our division directors and hospital leadership who have guided us to this moment, perhaps, the end of the beginning.

Courtesy of the artist, Michael Natter, MD


NYU Family Connect Featured on TODAY

Dr. Katherine Hochman talks with Al Roker about NYU Family Connect, a program that provides families of coronavirus patients with updates about their sick loved ones despite not being able to be physically present in the hospital.


Katherine Hochman, MD, Selected as NYU Grossman School of Medicine Graduation Speaker

Throughout the COVID-19 pandemic, Dr. Katherine Hochman has been a consistent, inspiring voice. Now, she'll lend her voice to the graduation ceremony for the NYU Grossman School of Medicine Class of 2020. “I am simultaneously humbled, honored, and thrilled to be addressing this year’s graduating class," says Dr. Hochman.


The Fourth Mission

The U.S. Department of Veterans Affairs runs the largest system of hospitals, outpatient clinics, and community living centers in the United States. Its three basic missions, widely known and endlessly scrutinized, cover health care, non-medical benefits from home mortgages to college tuition, and the management of cemeteries. But that’s not all.
     In 1982, Congress added a “Fourth Mission.” If you haven’t heard of it, you’re not alone. The Mission designates the VA as the backup for the country’s health care system during a national emergency declared by the president, meaning that nonveterans can be treated in its facilities. No president has ever invoked it—not during 9/11, or Hurricane Katrina, or Superstorm Sandy—until COVID-19.
     David Stern, MD, PhD, is a busy man, serving as Vice Chair for Education and Faculty Affairs in the Department of Medicine, and Chief of the Medicine Service at the Manhattan VA Medical Center, part of the VA’s sprawling New York Harbor Healthcare system that includes a second hospital in Brooklyn and a community living center in Queens. All of the 49 medical service physicians at the Manhattan VA’s 171-bed facility hold faculty appointments at the NYU Grossman School of Medicine, an affiliation dating back to 1961. Because it serves patients who are older, with preexisting conditions, it is widely known for its excellence in pulmonology, dialysis, and invasive cardiovascular procedures.
      Like all New York City hospitals, the Manhattan VA felt the full wrath of COVID-19. Never before had the “superblock” lining First Avenue experienced an “all hands-on-deck” emergency quite like this one. “While we did not face a shortage of ventilators, equipment, or potential ICU space, we faced a real challenge finding enough skilled ICU nurses to properly care for these sick patients," says Dr. Stern. "In response, the VA redeployed nurses from New York and New England to fill the void and maintain our high quality of care.” NYU doctors pitched in wherever they were needed most, and VA physician volunteers arrived from as far away as Texas and Washington state. Dr. Stern also tried to get the NYU Grossman medical students who graduated early into the mix, but VA rules, alas, do not provide a work category for those lacking an ACGME approved residency. “We actually got a bunch on board before we hit that roadblock,” he recalls.
      And what about the VA’s “Fourth Mission”? Since its implementation in late March, New York’s Harbor Health System has admitted close to 90 non-veteran COVID-19 patients in need of ICU-level care. It’s been particularly helpful in backstopping the city’s overwhelmed public hospitals—places like Elmhurst, the epicenter of the crisis, and Jamaica, where the oxygen distribution system failed from overuse. In New York City, at least, the “Fourth Mission” has worked exactly as planned.
     “The real praise belongs to our residents and fellows, to our VA nurses, our hospitalists, our ICU docs, our ER and urgent care docs—all working day and night to provide direct care to these patients,” says Dr. Stern. “They will forever be remembered for their compassion and sacrifice.”


Left to right: Dr. Neha Sathe, former NYU resident and chief resident, current second year PCCM fellow at UW; Dr. Vikram Padmanabhan, graduate of Albert Einstein College of Medicine, PCCM faculty at UW; Dr. Laura Evans

 

Critical Care: Laura Evans, MD, and Others Return to NYC to Help Combat Coronavirus

Laura Evans, MD, is no stranger to handling medical emergencies. In 2012, she led the evacuation of the intensive care units at Bellevue Hospital in the aftermath of Superstorm Sandy, and two years later headed the medical team that treated Dr. Craig Spencer, the first and only person to be diagnosed with Ebola in New York City.
     How does the current COVID-19 crisis compare? "This is a combination of huge scale and really prolonged duration,” Dr. Evans notes. “Ebola had the prolonged duration, but not the scale. Sandy had the scale, but not the prolonged duration.”
     Dr. Evans is now medical director of critical care at the University of Washington Medical Center in Seattle, the city that reported the first case of coronavirus in the US. But with her new home state showing signs of flattening the curve, Evans was quick to volunteer to return to Bellevue, where the number of cases was staggering. She recently spent two weeks working alongside her former colleagues and other volunteers, many of whom have a prior connection to NYU and Bellevue, including as graduates of our medical school and residency program.
      Returning in the thick of the crisis—when the number of patients was at its peak—was eye-opening. “I knew what the patient volume was, because colleagues had told me,” says Evans. “But it didn’t really prepare me for that feeling of walking into the hospital. There are so many patients, and they’re just so sick.” This includes several cases of multiple family members who are hospitalized at the same time, which gives a sense of how quickly this virus spreads in a city as densely populated as New York.
     In addition to the healthcare workers on the the front lines of patient care, Dr. Evans recognizes a group that she considers “unsung heroes” — environmental services and facilities staff. She notes that they are “absolutely essential” to the process, helping to keep the hospital up and running while not receiving the same attention as doctors and nurses do. These staff members include cleaning crews — so vital for infection control on an average day, but never more so than during the present situation — and those who have helped to create new patient care areas and workspaces on demand, often at warp speed.
      Being back at Bellevue also brought an unusual sense of comfort. “It’s been at the forefront of so many major events in history that have impacted public health and healthcare,” says Dr. Evans. “There’s this amazing esprit de corps during crisis. And this is no different.”


The Historian Is In: HIV/AIDS

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.

~~~

Unlike previous pandemics that had devastated New York City—Yellow Fever, Cholera, Smallpox, Influenza—AIDS had no history, not even a name, when it first appeared in the fall of 1980. Dr. Fred Valentine saw his first case at Bellevue in the form of pneumocystis pneumonia, a rare opportunistic infection, while Dr. Alvin Friedman-Kien saw his first case at the NYU Dermatology Clinic in the form of Kaposi’s sarcoma, an equally rare skin cancer. The only visible link at this time was that both patients happened to be gay men in their twenties with severely compromised immune systems. As these cases grew dramatically, researchers dubbed the mysterious condition “Gay-Related Immune Deficiency” (GRID). But when the net widened to include heterosexuals, such as drug addicts sharing needles and hemophiliacs receiving blood transfusions, it was renamed Acquired Immunodeficiency Syndrome, or AIDS.
      It seemed an eternity before the most basic questions surrounding the disease could be answered. Where did it come from? How was it transmitted? Why did it strike certain groups? With the only certainty being death itself, the panic was palpable. Stories appeared of funeral directors refusing to embalm the bodies of AIDS victims and EMS workers ignoring calls in gay neighborhoods. A poll of 350 Manhattan dentists in the mid-1980s showed “100 percent” of them opposed to treating someone with the disease. Even many doctors hesitated. “In refusing to deal with such patients,” a bioethicist wrote, “many physicians seem not merely to be saying, `Why Should I risk my life,’ but rather, `Why should I risk my life for the likes of homosexuals and intravenous drug abusers?’”
     As New York’s flagship public hospital, serving both the gay neighborhoods of Greenwich Village and the drug-plagued streets of the Bowery and the Lower East Side, Bellevue became the epicenter of the spreading disease. The doctors who worked and trained there in the 1980s—all from NYU Medical School—knew exactly what to expect. More patients were treated for AIDS at Bellevue than at any hospital in the United States, and more patients died there as well. A third-year NYU student described his morning rounds this way: “A young Hispanic male complains of a chest infection, which in any other hospital might suggest ordinary pneumonia. Here at Bellevue, we think of AIDS.” A resident who’d come “to serve the underserved” found herself “buried alive” by a seemingly endless plague. “Every day felt the same—legions of feverish, emaciated patients… There was a Third World feel to our existence, a soul-numbing tedium of affliction and despair.”
     Gowns, face masks, double gloves, and goggles became regular attire for doctors and nurses in the AIDS units, though many thought them too restrictive for effectively dealing with patients, especially after the disease’s mode of transmission was accurately determined. Over time, the secrets of AIDS would be exposed, marking its turn from a death sentence to a manageable disease. The vital work of identifying the Human Immunodeficiency Virus (HIV) took place in the laboratories of the National Cancer Institute in Rockville, Maryland, and the Pasteur Institute in Paris. NYU played a key role in researching Kaposi’s sarcoma and other cancers, while holding human trials for new drug therapies.
     By the year 2000, Bellevue was seeing far more AIDS patients in its outpatient clinics than on its wards, and in 2012—with the disease no longer among the top ten killers of young men in New York City for the first time in three decades—the hospital shuttered its AIDS Unit, a once unthinkable move. A momentous chapter in the history of NYU/Bellevue had closed—hopefully for good.


Left to right: Maureen Lohan- Mullens, NM; Pia Johnson, RN; Suzanne O’Sullivan, RN; Jessica Fasano, ANM; Thomasine Garofalo, CRN

 

Voices from the Front Lines: Pia Johnson, RN, on Challenges, Teamwork, and Hope

Pia Johnson, RN, began working at NYU Langone Health right out of nursing school, and celebrated her 23rd anniversary at our institution on March 16th—the day her unit was converted into an ICU to care for patients with COVID-19. She shares her experience with treating patients and how her colleagues at NYU have come together during this crisis.

What has it been like caring for the most critically ill patients during this pandemic?
I work on Kimmel Pavilion-15, the ICU, which was one of the first COVID-19 units that opened up. My unit is where they put all the ECMO patients. Not only did you have patients on ventilators and medicated life supportive measures (drips), but also on the ECMO machines and dialysis machines. Inside one room, you might find yourself with a patient on several machines at once, and you’d need a team to flip them and prone them.
     You could see that everyone was in it together. People would share ideas: Let's try this, and That’s awesome. That works. For example, putting the pumps and all the drips outside the room and running the IV lines, so we could work out there — because every time you go into the room you're constantly putting on and taking off gear.

What are the some of the biggest challenges you’ve faced?
We began with an eight-bed ICU and somehow managed to staff a 34-bed unit — nurses and doctors were coming from all over. Everybody was giving you what you needed.
     I think the other hard part was just facing this disease. We're walking into Covid-19 rooms all day. And then I’m going home to my family. I’m a mom, so I’m constantly wondering: “Am I doing everything I can to protect my everyone in my home, and protect my co-workers? Am I taking my PPE off the right way and putting it on the right way to protect myself? And it’s hard just to see people of all ages —young, old — dying. You’re watching them become so sick, so fast. You're watching the brilliant doctors we work with try to figure the reasons why.

What have been some of the positive takeaways during this experience?
We've really come together as a team. That’s what I’m so proud of. People came from every area, asking, “what can I do, I'm here to help,” even if they hadn't been on the floor in a while. Everybody pitched in, they rolled up their sleeves, they supported one another. I've met people that I've seen forever in the hallways, just never knew their name, along with others I’ve never met. Now we're working side by side, and we truly have a bond.
     From management, to senior leadership, to the staff, everybody just said, “Let's do this together.” And we really have — I think it's truly why we are still able to come to work every day, still able to leave our families to help these patients and do what we need to do.
     It also feels good to be recognized by the public for what we are doing inside the hospital, with donations of food and coffee, or skincare products. And then there’s the seven o'clock clap out. I finally had my first chance to go down and see it the other day, after all this time — it’s pretty amazing.

Can you share a specific moment of hope that you’ve witnessed?
I mentioned that we had patients on so many machines who were so very sick. It felt like every time we turned around, they were putting another patient on one of these machines. But then there have been times when I thought, Oh my god, Mr. So-and-So is sitting up or he's actually taking a few steps, or he's come off the device. I was at work last week and I got a thumbs up from a patient through the window of his room. I’ll never forget that.
     A few weeks ago, we discharged 6 patients to rehab. The staff lined the hallways and gave them a clap out send-off. The patients had tears in their eyes as they expressed gratitude to us, and the staff had tears as well. It was amazing to see these discharges happen.


Early Graduate on the Decision to Join the Fight

Peter Collin, who was among the early graduates of the class of 2020, describes his decision to join in the fight against COVID-19.

Upon being offered the option to graduate early and start on the wards, my gut instinct was to join as soon as possible and get to work. Joining the frontlines was what I wanted to do as a young physician interested in infectious diseases, especially as several close friends of mine were already working tirelessly during this pandemic. The logistics of the situation worked out easily, with individual on-campus housing, support from my family, and the fact that I would be staying on as housestaff here at NYU.
      But despite everything pointing to a simple yes, I still found myself anxiously sitting awake at night after submitting a non-binding survey expressing my interest. Countless conversations with my partner, my mentors, and my parents brought this internal struggle with my omnidirectional anxiety out into the open to be addressed. Through those conversations it was clear that, as rising interns, we were in a truly unique position to help, and that helping in a time like this could take on many different and valuable forms. Ultimately, I felt that I would be most useful in a clinical setting and was drawn to this option.
       The first week on the wards was disorienting but familiar. The expected butterflies of the first day of Intern year collided with the new protocols, discharge planning, grim conversations, and uncertainty that is defining the COVID pandemic. As someone going into Internal Medicine, it was refreshing to return to the wards, but the overarching presence of limited PPE hangs over everything we do. As a cautious new doctor, it is deeply uncomfortable to call a patient on the phone to discuss how they are doing and “eyeball” from the door instead of doing a full examination and speaking face-to-face. From the structure of the work day to phone-based check ins with patients, medicine in the era of COVID-19 has necessarily become more impersonal. At the same time, I am ever-aware of the persistent flow of rapid responses. In just a couple of months, Bellevue has become transformed. The familiarity of the snail-paced elevators and the bright-yellow East Wing paint is now made unfamiliar by new temporary workrooms and recently converted patient rooms. Its markings are different, but its inner strength remains.


COVID-19 Links

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

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

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

Resources for Managing and Surviving the COVID-19 Crisis
With thanks to Dr. Sandy Zabar and the DGIMCI team for compiling this resource guide of COVID information, complete with CME activities, mental health and emotional support, activities for parents and children, and free journal access.


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: Memento Mori

 

When Breath Becomes Air, Paul Kalanithi
This moving memoir by Paul Kalanithi, a young neurosurgeon facing a terminal cancer diagnosis, doesn’t shy away from the big questions: What makes life worth living in the face of death? What does it mean to welcome a child into the world as your own life ebbs away? How can we reconcile a lost future with embracing the joys of everyday life?
      In 2018, When Breath Becomes Air was selected as NYU Langone’s first Big Read, in which faculty, staff, housestaff, and students came together to read and discuss the questions raised by this compelling memoir. As a capstone to the Big Read, Dr. Paul Kalanithi’s widow, Dr. Lucy Kalanithi, visited NYU Langone to meet with students and to participate in a live taping of the podcast Person Place Thing with Randy Cohen.

How We Die: Reflections of Life's Final Chapter, Sherwin Nuland
In this bestseller, Sherwin Nuland, a surgeon and author, describes the process of dying with both a clinical and spiritual eye. By exploring the most common causes of death (i.e., old age, cancer, heart disease) through personal stories of the deaths of patients and loved ones, he attempts to demystify the processes of dying. This book sparked conversations about end-of-life care and the idea that a good death is inherently related to having lived a good life.

The Year of Magical Thinking, Joan Didion
Considered a classic book about mourning, The Year of Magical Thinking recounts the year following the sudden death of Didion’s husband, a time during which she was also caring for their acutely ill daughter. Didion explores grief with an unsparing eye, examining how it can affect memory and perception: “Grief turns out to be a place none of us know until we reach it….” The book won the 2005 National Book Award for Nonfiction and was a finalist for both the National Book Critics Circle Award and the Pulitzer Prize for Biography/Autobiography.

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