A Physician's Path Fighting COVID-19

To Begin

When it arrived, COVID-19 hit us like a tidal wave on our Northeastern shores. It was probably already here in early February 2020. The media had been reporting cases in Wuhan. Northern Italy was suffering. The Johns Hopkins website was tracking infections across the globe.

We knew Seattle had a cluster and, about a week later, we heard about a lawyer commuting between Manhattan and New Rochelle. He would become NYC Metro’s patient zero. By the second week in March, New Rochelle had over 100 positive cases and NYC was erupting with COVID hospitalizations. We watched as the first cases were heading our way.

Greenwich Hospital sits about three miles from the NY State border. Around mid-March we had a few hospitalizations. The ER was already churning COVID patients through its doors. If they didn’t need oxygen, we recommended they quarantine at home. We realized that our patients could become extremely hypoxic but were anticipating what was coming.

And then the inevitable happened on March 20. That was the day COVID hit us directly with a wave of severely acute cases.

The CDC was still advocating a no-mask policy. We didn't have reliable information from them or from the WHO. Doctors in China and Italy stepped up by creating podcasts and other useful information.

Boston’s Brigham and Women's hospital released an outline based on previous data for similar pulmonary injuries. This was meant to be a loose summary with guidelines for the frontline workers. Their simple message to us: use evidence-based medicine. I conveyed this to the frontline troops on the morning of March 20th. We were all afraid

In the Midst of It

COVID-19 as a disease is also like a tidal wave on the human body. Its impact on patients is often sudden and overwhelming. You can’t fully prepare for it—you just react. We quickly galvanized as a team and relied on one another's good ideas and instincts to get us through.

We knew how to treat acute respiratory distress syndrome, ARDS. We could mechanically ventilate patients. We also knew how to respond to blood clots, cytokine storms, and viremia-led multiple organ dysfunctions. But the severity of all of these things happening at once to so many patients at the same time was unlike anything anyone had ever seen.

We were consuming ventilators, IV lines, medications and sedatives at incredible rates. Each hour brought new problems. As a team, we figured out how to deliver high-quality medical care with limited staff, equipment, and information. At the same time, we ensured our staff’s safety and allayed their fears, anxiety, and stress.

We quickly invented new practices on the fly. We placed IV poles outside patient rooms to protect nurses from exposure. We cut patients’ rooms doors in half, adding windows so we could visually monitor from the outside in. And we wrote vitals on the windows for all to see.

Many patients were young. And often, these young patients were very hypoxic. Any muscle movement above the respiratory diaphragm could cause dangerously low oxygen levels. Young people are also strong and need more powerful sedatives. We had to deeply sedate and paralyze them.

Many standard protocols seemed frivolous under the circumstances and so we modified them. We used IV lines longer, changed ventilator circuits less frequently, and doubled oxygen levels to keep patients off ventilators.

Initially, Hydroxychloroquine was the drug of choice. We feared shortages and decided to save doses for hospitalized patients.

Greenwich Hospital’s infectious diseases doctors are early participants of clinical trials. Through them and their connections we could, in a way, bypass the FDA to gain quick access to what were rumored to be helpful elixirs like Remdesivir, Tocilizumab, and convalescent plasma.

Patients needed rapid relief. We expedited Institutions Review Board (IRB) processes, writing protocols quickly to treat our pandemic patients while adhering to the scientific method.

The virus caused inflammatory organ systems destruction and routine medical care was inadequate. We grasped at anything to save a life and shared timely insights on effective treatments, failures, and patterns.

As part of each COVID patient’s blood work, we measured d-dimers, an inflammatory marker that suggests clotting is taking place. We quickly began to perceive a trend. Some patients’ d-dimer levels remained constant. Others had escalating d-dimer levels and, with those, thrombotic events began to occur. First one patient, then three, and soon over a dozen. We made a battlefield decision: anticoagulate if the d-dimer goes above a level of three or if the slope of the curve becomes steep.

The decision to treat a D-dimer of three may seem completely arbitrary. But a doctor’s deeper training surpasses casual Googling. We mustered our courage and made the tough calls. With zero evidence to guide these early decisions, we simplified.

How do we treat this new pathologic process to best protect the patient? How long are we supposed to keep patients who survive to discharge on anticoagulation? We chose three to six months, which is standard for leg or lung blood clots (but still not formally standardized for COVID clotting).

Data continues to this day to emerge from the healthcare setting—from hospitals, doctors, and nurses in the field.

Our sickest COVID patients were critically ill, requiring full life support. To keep them alive they needed central lines—large IV catheters placed under sterile techniques into the internal jugular vein—to deliver powerful meds directly to heart chambers and the central blood supply.

We did clean central insertions. And we protected patients from pressure injuries while they were paralyzed, 100% dependent on us to position their comatose bodies safely. We had zero infections.

Greenwich Hospital's results of good care were the best in the nation. I still don't know why. Likely, there were multiple factors. But I'm pleased by the results because I know I played a part in our success.

And In the End

People often ask what my experience of COVID was like. In retrospect, having been in the middle of the fight, with no choice but to focus on the challenge at hand, I describe it as almost therapeutic. We didn’t have time to worry about whether we could get pasta or toilet paper, which had been entirely wiped out at local stores. We worried instead about things such as PPE requirements. Would this really be enough to protect us?

I would even say that the experience was glorious in some ways. We had an ill-defined mission but a well-defined purpose. We openly shared our ideas and pattern recognitions of this novel virus pathology across specialties. And by sharing information, we saved lives.

We became wartime leaders. Wartime leaders can make mistakes but they are effective. They’re not stymied by minutiae and process. They have the vision, courage, and analytical prowess to do what is right and necessary in the moment, to weigh risks in order to favor the odds of a better outcome.

Plans and emails rained upon us. The vision was cloudy and the information changed rapidly. But throughout the uncertainty, I formulated my actions. Was I going to run into the fight or away from it? Would I face the possibility of death head on, or try to hide?

I learned a lot about myself. I have the courage to stand up for my beliefs.

This pandemic continues. And future ones await. But we'll be better prepared because we invented new and useful ideas throughout our initial battle with COVID-19.