3/30/2020 | BY Michael Vitale, MD

NYC and New York Presbyterian Hospital System Updates

Greetings from NYC and New York Presbyterian Hospital System. Unfortunately, we are now the Worldwide epicenter of the Corona. While I wish we were all doing alot of other things (including prepping presentations for the POSNA Annual Meeting!), here we are and let's find the best way out. Stay safe and remember: "The only way out is through"  

We have alot of COVID at the current time across our Hospital system. Across nine hospitals as of this AM we have about 1,500 cases admitted. ERs are swamped with pretty sick patients but about half get discharged with GI symptoms or manageable respiratory distress. (50% admit rate has been typical). About 20% of those admitted end up in the ICU - most on a vent and a few on ECMO. We have a number of ante/post partum moms - more on this below.

We have 11 patients less than 21 years of age. Severity of disease is relatively low for most young people but at least one in pretty sick.

Unfortunately, it's clear we are on the Milan curve, meaning we will approach peak faster than we would like and this will create challenges. Here are the most current estimates of  when we will hit peak in each state and ramifications for resources. (https://www.mssurg.com/covid)

Here at NYP, we were hit early and hard and supply chain has been a big issue. We're making great efforts to strengthen supply chain and increase capacity but have been perilously low in surgical masks, (esp N95), swabs, and testing kits. Unfortunately, these shortages create and require some creative solutions that many of you will be able to avoid if your surge is pronged a bit. As a result, we are seeing some of our front line staff become sick. Staff shortages are probably inevitable. All front line providers are getting N95 masks at the current time. Everyone wears a surgical mask in any public area of the hospital. I'd urge all of you at places earlier than we are on the curve to do this early, rather than make the same mistake that others have made. Most health care workers in Wuhan, Milan and also here, got sick early before they recognized the importance of PPE and ridiculously stringent hygiene.

Here are two different perspectives on the risk to health care workers. Bottom line is that staff seem most at risk early when our guard is down and that health care worker infection can be sig limited with aggressive attention to hygiene and PPE. China showed us that the early peak in health care workers can be almost eliminated with appropriate and extreme PPE countermeasures, countermeasures that are probably not practical or  available at this time here.

https://www.newyorker.com/news/news-desk/keeping-the-coronavirus-from-infecting-health-care-workers

Contrast this with the Italian experience:

https://www.bloomberg.com/opinion/articles/2020-03-24/the-coronavirus-crisis-is-putting-surgeons-at-risk-too

Our residents were recently pulled into rotation into the ER and out surgical staff will follow doing shifts in the ER this week.

Acknowledging that there will be widespread exposure and that quarantine after every exposure without symptoms will decimate workforce, NYP now allows health care workers to return to work with a mask as long as they are entirely asymptomatic and as long as they are afebrile. ID suggests that you all take your temp at least 2x/day to be alert of disease in the asymptomatic stage. 50% of patients have symptoms by day 4 but 10% of patients who develop symptoms dont develop symptoms until day 10 and you need to keep this in mind when thinking about your behavior outside the hospital. Some of our people are wearing a mask at home.

If and when you have sufficient testing to know who has impending disease and who serological evidence of immunity, all this will change in a good way.

There is absolutely no elective surgery here. ER is on diversion so ortho (adult and peds) come directly to clinic after initial screen. I hope you shut off surgery and most out patient things early enough. The lesson of other places, is that this was not taken seriously enough early enough.

We have set up "platoon" style rotation for staff coverage of emergencies: 2-3 days on and then 12 days off allowing quarantine and minimizing transmission of disease during asymptomatic period. We have a back up assigned in case one of us gets sick. Attached is a good article summarizing some of the rationale for this.

Even though we do not have enough testing to test outpatients of even exposed providers, we are testing all prepartum women as we have seen high incidence of asymptomatic disease and potential spread.

Acknowledging that we will soon confront shortage of respirators, our ICU teams have figured out a way to share a single respirator among 2 patients. This will be a big help and suspect you may need to do same.

I hope that this post is in some way helpful. While the worst is ahead, recognize that China has this in its rear view mirror and we will too before long. Italy is probably coming off peak too.

For more information, the link below is a fantastic compilation of resources geared towards surgery residents but useful for everyone. There are links to the CDC and WHO guidelines, UW Guidelines, Mount Sinai guidelines, surgical and non-surgical guidelines, vent guidelines, sites for stats and data, as well as infographics, instructional videos, and literature: https://www.mssurg.com/covid

We will get to the other side of this but now is the time to create the best trajectory for the way forward. Cant wait for what I think will be a busy summer taking care of injured and twisted kids and getting back to what we do best. And already looking forward to IPOS 2020 and POSNA 2021!

Finally, leaving you with a short video of NYC last night (NYC-Corona-HCW.mov). Here you see  residents of NYC expressing their appreciation for HCW every night for 7 minutes at 7PM.  

Makes me proud to be a New Yorker and proud to be a physician.

This is what we are called to do and this is why we do it...

With admiration for all of those on the front line and for all of you who are juggling so many competing responsibilities at the current time-  

Michael

Michael Vitale MD MPH

Ana Lucia Professor of Pediatric Orthopaedic Surgery and Neurosurgery
Vice Chair, Quality and Strategy, Orthopedic Surgery
Columbia University Medical Center

Director, Division of Pediatric Orthopaedics
Chief, Pediatric Spine and Scoliosis Service
Morgan Stanley Childrens Hospital of New York - Presbyterian