Just about a month ago, people stricken with the new coronavirus started to arrive in unending ranks at hospitals in the New York metropolitan area, forming the white-hot center of the pandemic in the United States.
Now, doctors in the region have started sharing on medical grapevines what it has been like to re-engineer, on the fly, their health care systems, their practice of medicine, their personal lives.
Doctors, if you could go back in time, what would you tell yourselves in early March?
“What we thought we knew, we don’t know,” said Dr. Nile Cemalovic, an intensive care physician at Lincoln Medical Center in the Bronx.
Medicine routinely remakes itself, generation by generation. For the disease that drives this pandemic, certain ironclad emergency medical practices have dissolved almost overnight.
The biggest change: Instead of quickly sedating people who had shockingly low levels of oxygen and then putting them on mechanical ventilators, many doctors are now keeping patients conscious, having them roll over in bed, recline in chairs and continue to breathe on their own — with additional oxygen — for as long as possible.
The idea is to get them off their backs and thereby make more lung available. A number of doctors are even trying patients on a special massage mattress designed for pregnant women because it has cutouts that ease the load on the belly and chest.
Other doctors are rejiggering CPAP breathing machines, normally used to help people with sleep apnea, or they have hacked together valves and filters. For some critically ill patients, a ventilator may be the only real hope. (...)
Breathing Room
“Never in my life have I had to ask a patient to get off the telephone because it was time to put in a breathing tube,” said Dr. Richard Levitan, who recently spent 10 days at Bellevue Hospital Center in Manhattan.
Why is this so odd? People who need breathing tubes, which connect to mechanical ventilators that assist or take over respiration, are rarely in any shape to be on the phone because the level of oxygen in their blood has declined precipitously.
If conscious, they are often incoherent and are about to be sedated so they do not gag on the tubes. It is a drastic step.
Yet many Covid-19 patients remain alert, even when their oxygen has sharply fallen, for reasons health care workers can only guess. (Another important signal about how sick the patients are from Covid-19 — the presence of inflammatory markers in the blood — is not available to physicians until laboratory work is done.)
Some patients, by taking oxygen and rolling onto their sides or on their bellies, have quickly returned to normal levels. The tactic is called proning. (...)
At Lincoln Hospital in the Bronx, Dr. Nicholas Caputo followed 50 patients who arrived with low oxygen levels between 69 and 85 percent (95 is normal). After five minutes of proning, they had improved to a mean of 94 percent. Over the next 24 hours, nearly three-quarters were able to avoid intubation; 13 needed ventilators. Proning does not seem to work as well in older patients, a number of doctors said.
No one knows yet if this will be a lasting remedy, Dr. Caputo said, but if he could go back to early March, he would advise himself and others: “Don’t jump to intubation.” (...)
“Intubated patients with Covid lung disease are doing very poorly, and while this may be the disease and not the mechanical ventilation, most of us believe that intubation is to be avoided until unequivocally required,” Dr. Strayer said.
This shift has lightened the load on nursing staffs and the rest of the hospital. “You put a tube into somebody,” Dr. Levitan said, “and the amount of work required not to kill that person goes up by a factor of 100,” creating a cascade that slows down laboratory results, X-rays and other care.
Now, doctors in the region have started sharing on medical grapevines what it has been like to re-engineer, on the fly, their health care systems, their practice of medicine, their personal lives.
Doctors, if you could go back in time, what would you tell yourselves in early March?
“What we thought we knew, we don’t know,” said Dr. Nile Cemalovic, an intensive care physician at Lincoln Medical Center in the Bronx.Medicine routinely remakes itself, generation by generation. For the disease that drives this pandemic, certain ironclad emergency medical practices have dissolved almost overnight.
The biggest change: Instead of quickly sedating people who had shockingly low levels of oxygen and then putting them on mechanical ventilators, many doctors are now keeping patients conscious, having them roll over in bed, recline in chairs and continue to breathe on their own — with additional oxygen — for as long as possible.
The idea is to get them off their backs and thereby make more lung available. A number of doctors are even trying patients on a special massage mattress designed for pregnant women because it has cutouts that ease the load on the belly and chest.
Other doctors are rejiggering CPAP breathing machines, normally used to help people with sleep apnea, or they have hacked together valves and filters. For some critically ill patients, a ventilator may be the only real hope. (...)
Breathing Room
“Never in my life have I had to ask a patient to get off the telephone because it was time to put in a breathing tube,” said Dr. Richard Levitan, who recently spent 10 days at Bellevue Hospital Center in Manhattan.
Why is this so odd? People who need breathing tubes, which connect to mechanical ventilators that assist or take over respiration, are rarely in any shape to be on the phone because the level of oxygen in their blood has declined precipitously.
If conscious, they are often incoherent and are about to be sedated so they do not gag on the tubes. It is a drastic step.
Yet many Covid-19 patients remain alert, even when their oxygen has sharply fallen, for reasons health care workers can only guess. (Another important signal about how sick the patients are from Covid-19 — the presence of inflammatory markers in the blood — is not available to physicians until laboratory work is done.)
Some patients, by taking oxygen and rolling onto their sides or on their bellies, have quickly returned to normal levels. The tactic is called proning. (...)
At Lincoln Hospital in the Bronx, Dr. Nicholas Caputo followed 50 patients who arrived with low oxygen levels between 69 and 85 percent (95 is normal). After five minutes of proning, they had improved to a mean of 94 percent. Over the next 24 hours, nearly three-quarters were able to avoid intubation; 13 needed ventilators. Proning does not seem to work as well in older patients, a number of doctors said.
No one knows yet if this will be a lasting remedy, Dr. Caputo said, but if he could go back to early March, he would advise himself and others: “Don’t jump to intubation.” (...)
“Intubated patients with Covid lung disease are doing very poorly, and while this may be the disease and not the mechanical ventilation, most of us believe that intubation is to be avoided until unequivocally required,” Dr. Strayer said.
This shift has lightened the load on nursing staffs and the rest of the hospital. “You put a tube into somebody,” Dr. Levitan said, “and the amount of work required not to kill that person goes up by a factor of 100,” creating a cascade that slows down laboratory results, X-rays and other care.
by Jim Dwyer, NY Times | Read more:
Image: uncredited
