'Unpredictable': NYC's doctors share lessons from the toughest month at the epicenter of the coronavirus pandemic
- New York City's hospitals were slammed in April by the peak of the coronavirus pandemic.
- Along the way, doctors there learned a lot more about the disease, making decisions that can help prevent additional deaths.
- As the surge of new patients starts to slow, the city is grappling with what's ahead, as surgeries start to resume and emergency rooms empty out.
- Visit Business Insider's homepage for more stories.
As the coronavirus pandemic reached its peak in New York, the overhead announcements at Maimonides Medical Center became a grim reminder of the disease's toll.
Pages signaling a code blue, an alert that a patient's condition had deteriorated rapidly, were a constant backdrop. To combat the grim mood, the hospital, in Brooklyn's Borough Park neighborhood, decided to play music any time a coronavirus patient was discharged. "Beautiful Day" by U2 began to supplant the urgent pages, Dr. Patrick Borgen, the hospital's chair of surgery told Business Insider.
By the end of April, the hospital had discharged 854 coronavirus patients. Maimonides is still filled with patients with COVID-19, the disease caused by the novel coronavirus, but has managed to close a few intensive care units it opened at the outbreak's peak.
April was deadly in New York. The state's coronavirus death toll soared from about 3,000 to above 18,000 over the course of the month. It was also a month of learning, as hospitals around the city developed new ways to treat seriously ill patients fighting for their lives.
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Doctors battled a disease that often felt frighteningly unpredictable, with some people experiencing no symptoms, some having a mild flu-like illness, and others needing intense hospital care.
"It's still highly unpredictable," Borgen said.
The toll of coronavirus in New York in April
Kuffner grew up in New York and did his emergency medicine residency in New York City.
He and got in touch with Dr. Mark Kindschuh, a friend who trained with him and now serves as the chairman of emergency medicine at NYC Health + Hospitals/Coney Island, one of the public hospitals in Brooklyn.
Kindschuh mentioned that a number of attendings were out sick, leaving the emergency room short staffed. So, Kuffner, based in Pennsylvania, worked to get emergency credentialed as a doctor in New York to help out.
He arrived in Brooklyn near the end of March.
A few hours into his first shift, first responders brought in a patient who was in his 40s and was seriously sick with the coronavirus. The patient, who had no prior medical problems, died in the emergency department a few hours later.
"When you see someone who's younger than you, who's generally probably as healthy as you, ends up dying, it leaves a lasting impression on you," Kuffner said.
It's not an uncommon occurrence among healthcare providers on the front lines, Kuffner said.
"We've all had that experience. This is a very unpredictable disease."
At the start of April, more than 500 patients were dying of coronavirus in New York state every day. A week into the month, the daily death toll reached 799.
The outbreak ebbed from there, but Brooklyn's hospitals felt the high death tolls for weeks.
At Maimonides, there were as many as 30 people dying each day, Borgen said. Some had to say goodbye to their loved ones using iPads, because visitors aren't allowed in the hospital to protect them from the coronavirus.
In Coney Island, the volume of severly ill patients overwhelmed the hospital.
"The hospital resources in general was stressed, the emergency department was stressed," Kuffner said. He described the number of patients and how seriously ill they were as taking the busiest shift ever and multiplying that by 10.
"That wasn't just the first day," Kuffner said. "That was every single day for weeks and weeks."
In New York state, new hospitalizations reached as high as 18,825 people a day in the middle of April. Hospitals had to get creative to find space for patients in operating rooms and lobbies.
"The deepest fear we had was being overrun and having to ration care and having to make impossible decisions," Borgen said. The hospital was able to make it through without having to make those decisions, he said. Maimonides went from 600 beds to 1200, and from 50 ICU beds to 150.
An evolution in how to care for COVID-19
Over the course of the pandemic, Maimonides has enrolled 400 patients in clinical trials to test coronavirus drugs.
For someone like Borgen, who's been involved in cancer drug clinical trials throughout his career, the fact that 400 patients were enrolled so quickly "is an enormous feat."
That includes enrolling patients in a closely watched trial of the antiviral remdesivir, an experimental drug made by Gilead Sciences. On Friday, the drug got authorized for emergency use by the Food and Drug Administration. While the drug is mainly being studied in critically ill COVID-19 patients, Borgen said he sees its benefit coming out if administered early.
"We believe that it has helped some patients but we really believe the real benefit will be giving it earlier in the course of the disease," Borgen said. "The future of an antiviral like remdesivir will be much much earlier maybe as soon as a test comes back positive."
Over the course of a month, Borgen said, the hospital's approach to caring for patients with the disease, from treating blood clots to using ventilators, has evolved.
In particular, the emergence of the severity of blood clots as a complication related to COVID-19 has changed the way the hospital treats all COVID-19 patients.
Clots can wreak havoc on the body, traveling and blocking up veins, leading to strokes, heart attacks, kidney problems, lung problems, and more. They're common in hospitalized patients, but appear to be popping up more frequently in COVID-19 patients severely ill with the disease.
To counter that, Borgen said the hospital now keeps an even closer eye on them, using anticoagulation treatments to keep the blood from clotting throughout their hospital stay. The hospital is also discharging patients on blood-thinning medication, he said.
For Kuffner beginning to care for COVID-19 patients brought an understanding that the disease did more than just impact a person's lungs.
"I had in my head it was primarily if not exclusively a pulmonary disease," Kuffner said.
Over time, he realized that wasn't the case. Yes, a lot of the severe complications have to do with the lungs, but he saw it affecting all organs. For instance, over time he started putting patients on full anticoagulation doses when they came into the emergency room, rather than the lower preventive doses, Kuffner said.
"I started to realize that what I went in thinking really wasn't the true extent of COVID-19," Kuffner.
One constant in Kuffner's treatment of patients coming into the ER was a pulse oxymeter given to him by Catherine Kindschuh, Mark's wife, and a nurse in the emergency department. The handheld device measures the level of oxygen in people's blood, giving a snapshot of how well patients were doing and whether they needed to be admitted or could be sent home.
"I used that from the first patient I saw to the last patient," Kuffner said.
'The uncertainty of the future'
While the floors and ICUs of hospitals still are filled with coronavirus patients, emergency departments are relatively empty.
"It's a bit of an odd place to be to be in an emergency department that is quieter than it's ever been," Dr. Trevor Pour, an emergency medicine doctor at Mount Sinai Health System, told Business Insider.
By the end of the month, the emergency department at Coney Island had calmed down, too, seeing fewer patients coming in than at the same point last year. Kuffner on April 29 went back home after a month in Brooklyn, though he plans to get credentialed in New York officially and stay on call just in case he's needed.
Hospitals in New York are starting to think about restarting some of the procedures they put off to make way for a surge in COVID-19 patients.
Borgen, the chair of surgery at Maimonides, is expecting to go back into the operating room on Thursday to perform three mastectomies on breast cancer patients who have had the procedure delayed because of the pandemic.
Before he does, he'll need to be tested for the novel coronavirus and have a negative result for 48 hours. So will his patients. At the center of concerns: worries about what undergoing surgery while sick with COVID-19 might mean.
"What's driving all of this is concerns that general anesthesia could be very dangerous in someone with active COVID-19," Borgen said.
After weeks and weeks of battling the pandemic, there is some interest in getting hospitals back to business.
"There's a real sense of our team of wanting to get back to some kind of new normal," Borgen said.
Even so, it'll be important to weigh the benefits of restarting procedures and "normal" hospital life with confronting what might be ahead.
"The big thing on our mind is the uncertainty of the future," Pour said. "What on Earth are we going to see in a month and how are we going to prepare for it."
As he heads back into his role as a CMO at J&J, Kuffner has been imparting what he observed in Brooklyn to family, emphasizing the importance of maintaining protective measures like social distancing.
"We as a society cannot let our guard down," Kuffner said. "We don't want to go back to another surge-like system. No healthcare provider involved ever wants that to happen again."
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