Tuesday, April 7, 2020

COVID-19 Pandemic, A feeling of Earthquake Déjà vu

I felt this way before by under very different circumstances, almost 10 years to the date.   I am writing reflections about the events of the last few weeks, culminating in a feeling of near despair. I've been there before, writing thoughts as a therapy session, returning from Haiti one week after that infamous earthquake (NYT). I never felt any fear of heading to the stricken island. On returning, post-traumatic stress quickly set in.  But somehow, the same feelings brought back its ugly head - this time, I have a sense of anger.

I was driving home last Friday.  As usual, XM radio was on CNN.  The press conference with the chief politician came on.  Yes, the bickering started.  This time it was a fight concerning how many respirators the federal government will send to New York. Have mercy; I thought, patients would die without ventilators. All the bragging and ignorant noise irritated my nerves. It takes careful staring into the patient's cough to insert a breathing tube into the trachea withing a short 20 seconds. "Let them f--- try this without PPE (Personal Protective Equipment," I shouted in the car, slamming on the gas pedal.  Where are the flipping PPEs? Doctors, nurses, respiratory therapists, and other hospital workers lacking proper equipment, not enough ventilators - is not supposed to be happening here. We are in the USA. Now, I know why I feel sad and irritated.

In preparation for a coming wave of sick people stricken by the coronavirus, allow me to share my reflections of last week.  More anomalies were comparing a tragedy in the US with that of the poorest country in the hemisphere, Haiti felt like deja-vu. 

Thank God, this viral syndrome does not affect children as much as adults.  So, we had weeks to prepare our pediatric area, train our teams, and gather our materials at my hospital (TBHC). 

I imagine an earthquake with early warning signs.  These were not aftershocks before a second big one, but now it's three months since the outbreak in Wuhan.  What shook me up is the fact that China rushed to build two hospitals in only two weeks at the same time declared a draconian quarantine protocol.  The Chinese certainly sounded the alarm, a warning that the world did not heed.  

The surge plan for the pediatric area will be near completion by next week. The New York mandate came out, Gov. Andrew Cuomo Orders Hospitals to Increase Capacity by 50%. We quickly planned to double our private rooms, fit them with double-wall oxygen supply.  At the same time, pediatric patients with mild illnesses will stay home or discharged and managed over the phone.  As the crisis mounted, the pediatric floor remained quasi empty.  We quickly realized that we would have to increase our age range from 21 to 25 years of age and higher because of the swell of adult patients crowding the emergency room.  The daily change in conditions urged us to come out of our comfort zone and begin caring for young adults in a way to decongest the adult floors. 

One lesson learned after the Haiti earthquake was a gross lack of training for necessary resuscitation procedures.  A grave shortage of human resources was also evident.  As we surged our space capacity, an apparent shortage of nursing staff came in view. Before the weekend, pediatric residents shifted from their regular duties, and seven received basic training in nursing ICU duties. The goal was to pair them with a skeleton staff of nurses to augment the staff capacity because several of them had fallen sick to the disease. 

During the same week, news broke from Italy. Doctors were no longer placing patients older than 60 years on life-sustaining equipment. In essence, they first considered younger patients with a higher chance of survival.  Déjà vu.  My earthquake experience in Haiti taught me well. I chose to give the last shot of ceftriaxone [an antibiotic] left to a patient who underwent a successful amputation for a gangrenous leg over a gasping pediatric patient in severe sepsis.  This scenario is not novel, frequently simulated in NY state with drafted guidelines to ration scarce resources.  We have watched documentaries about pandemics and attended disaster courses, informed about stockpiled ventilators for something just like this. Well, here we are, actually writing a policy allocating scarce resources in a time of crisis. As I read through the draft document for my hospital, there was little relating to children.  I began thinking; we now have two very sick children both on respirators.  Could we ever consider withdrawing one or two of these challenged patients for the benefit of another with greater longevity?  What if a premature infant birthed at a time to compete with a healthy 21-year-old with COVID-19 infection in respiratory failure?  Would this policy call for someone to be "King Solomon"? 

That same night as we nearly converted our pediatric floor to accommodate adults, a seven-day old presented with severe jaundice.  His pediatrician frantically called-in for a bed.  She insisted on having him stay close to the community as other large hospitals were diverting all pediatric patients far away from home.  We had to make space.   How could we manage such a massive influx of sick patients with coronavirus infection and ignore our community of patients with sickle cell disease? This other patient also required special attention. 

 The earthquake caused by COVID-19 has just begun to shake.  No-one knows where, when, and how this will end.  The ground keeps shifting and forces us to readjust day by day.  As in Haiti's experience, we will learn hard lessons.  Likewise, the whole world is watching.  The vast difference is that in Haiti, we lost over 220,000-300,000 souls in a tiny corner of earth's space and a small span of time.  This will never happen here. I refuse to imagine a shakeup of this magnitude.  Not in the USA. 

Chief, Pediatric Critical Care
Director, Pediatric Inpatient ServiceTBHC
Assistant Professor of Clinical Pediatrics
Icahn School of Medicine at Mount Sinai