番茄社区

For 59 days, Craig Smith, MD, surgeon-in-chief at had been posting a daily update about working through the COVID-19 crisis in New York. His messages came to an end last week, as his hospital and others in the state had reached the declining side of the coronavirus curve.

"With the terror diluted, people seem happier and the crisis feels less compelling, but fear is still there," Smith wrote in his . "Fear of future surges, fear of economic struggle, and fear of the unknown, because 'normal' is gone."

Many clinicians in New York are breathing a sigh of relief as the first wave of COVID-19 winds down, with new hospitalizations and deaths down significantly from a mid-April peak. After going on lockdown on March 22, the state has successfully flattened the curve.

Even emergency physician Craig Spencer, MD, MPH, also of NewYork-Presbyterian, was able to take a few days off last weekend: "Today was the first time since early March that I spent every waking moment with my daughter," Spencer .

But with Gov. Andrew Cuomo outlining -- albeit regionally, based on extended reductions in hospitalizations and deaths along with other criteria -- New York City's clinicians aren't sure about exactly what the future holds. Will there be a second wave? When will it come? In the fall, after a summer reprieve? Will it be worse than the first?

Down from the Peak

David Reich, president and chief operating officer of The Mount Sinai Hospital in New York City, said healthcare workers are still stressed, but it's a different type of stress from early days of the surge and the peak.

"Our stress levels were extraordinarily high when we didn't know if we'd have enough staff, space, and ventilators as the number of patients was growing exponentially," Reich told 番茄社区. "As the curve flattened, it was still stressful, but the staff felt they met the peak of this. Then they started to feel much more optimistic as we started to come down the curve."

But, Reich noted, it's "been a very slow climb down."

Reuben Strayer, MD, an emergency physician at Maimonides Medical Center in Brooklyn, described his full trajectory in . For clinicians at Maimonides, the warnings came in early March when patients started coming in with fever, chest pain, and trouble breathing.

By mid-March, patients were coming in sicker, and more lung CTs were being done, in an attempt to separate out the COVID-19 patients. By then, the majority -- even those not coming in for COVID -- had ground glass opacities.

"I saw a middle aged man who was on mile 40 of a 60-mile bicycle ride, came in in full spandex after getting hit by a car, fractured femur," Strayer wrote. "No chest complaints, fever, nothing. ... CT chest: peripheral ground glass opacities. That was when I realized how prevalent COVID was in New York City."

By the last week of March, the emergency department "became a place familiar only to those who do battlefield medicine," he wrote. The emergency department had transformed into an open ICU with patients on oxygen or ventilators. "Code blues were called overhead seemingly every 30 minutes."

By mid-April, Strayer had contracted COVID-19 himself, right around the time the surge was peaking. Now back at work, he said the department is slow, mainly because people are afraid to come to hospitals for fear of catching the virus.

COVID-19 patients are still dying at Maimonides every day, "and we expect this to continue for many months," Stayer wrote, "but now we can handle the volume."

Time to Reflect

Suraj Saggar, DO, chief of infectious disease at Holy Name Hospital in Teaneck, New Jersey, which was at the center of one of the state's early outbreaks, said clinicians who worked for weeks on end are now dealing with PTSD as they have time to reflect on their experiences.

"All doctors are used to non-stop work," he said, "but this was something we've never experienced. The anxiety and fear of bringing it home. But you settled into a pattern and just got used to it. You come home exhausted, you wake up and do it again."

"Now that you have time to reflect, you realize you missed things," Saggar said. "Even if I was physically at home, I wasn't there mentally."

While clinicians are used to dealing with loss, the volume of it has an even greater impact now, Saggar said.

"You're always aware when you have losses, but when you see families wiped out, patients in their 40s and 50s with young kids, sometimes children, it hits home," he said. "Before there was just so much volume you didn't have time to reflect. You would triage, treat, and move on."

Cleavon Gilman, MD, an emergency medicine resident at NewYork-Presbyterian, said being outside the hospital seeing people sitting on blankets in parks "plays tricks on your mind" because it's such a disconnect from being inside, where he would see 20-somethings being intubated.

Gilman worked as a U.S. military corpsman in Iraq in 2004 and said his experience in New York was "worse. I can't escape this experience," he told 番茄社区. "Everyone I know can be in danger."

Return to 'Normal'

Saggar said Holy Name has taken steps to bring patients back in for non-COVID issues, including an intense cleaning and developing pathways so that the "slow trickle of COVID patients" never interact with those who come to the hospital for other reasons.

Patients will be asked to bring minimal items from outside the hospital, and all meals will be provided, as a way to minimize outside items that may not be sanitized appropriately.

Brian Lima, MD, director of the heart transplant program at North Shore Hospital in Manhasset, New York, had his cardiothoracic ICU converted into a COVID-19 ICU, where he spent the past two months managing ventilators and treating the sickest patients.

Now that his regular CICU has returned, "we're slowly starting to do more regular heart surgery, and we're going to resume doing heart transplants."

Lima, who recently about his journey to building Long Island's only heart transplant program, says he's "cautiously optimistic" about getting back to a semblance of normal. All patients will be tested for COVID before procedures, but given issues with false negatives, clinicians will continue to wear N95s and other personal protective equipment (PPE).

"It's going to be that way for the foreseeable future," Lima told 番茄社区. "As long as we have to cohabitate with COVID, we're going to practice universal precautions."

Reich noted that convincing patients to come back to the hospital is critical but difficult. "It's time to turn our attention to people who have not been getting care for all these weeks now," he said. "We need to create an environment where people feel safe, so they can come and have their disease treated. Not everything can be done via telemedicine."

Subsequent Waves?

Many states are re-opening, but are "nowhere near ready to come off of lockdown, from a public health perspective," Stayer wrote on his website. "But the public won't tolerate this much longer, so we're going to open up, and new cases/deaths will start to rise."

Gilman said he's not optimistic that future waves will be prevented or easier to deal with.

"Cases are down because people are in quarantine," Gilman told 番茄社区. "The reality is that this virus is still in the community. We have no treatment, no vaccine."

He expects a second wave as early as June or July "because people are going outside and to the beaches now. When the temperature spikes again, people are going to go outside and spread the virus."

Saggar said it's impossible to predict what will happen next, but is hopeful that, at least in northern New Jersey, which is less densely populated than New York City, testing and contact tracing infrastructure can be an appropriate guard.

"The hope of this has always been that if we do have cases we can quickly do containment," he said. "We've done the social mitigation to move to that containment process."

He noted, however, that in January and February, his team had constant meetings and planning for the arrival of COVID-19, but "when things happened, they exceeded our wildest expectations."

"We all anticipate further surges, I think that's inevitable," he said, "but hopefully we can limit them."

Comment