April 10, 2020 "Good Friday"
from Dennis Dimaculangan, M.D. - SUNY-Downstate Medical Center
from Dennis Dimaculangan, M.D. - SUNY-Downstate Medical Center
On call today. Going in at 5 p.m. Back to the trenches. Forgive me for using this social media forum for a personal diary. I never posted like this before, but this is serving as a cathartic and therapeutic outlet for me. All the prayers and well wishes I get from you, my friends, give my colleagues and me on the front lines strength and hope to continue what we are doing. Thank you all!
Until we have a vaccine, an antiviral, plasma antibodies, hydroxychloroquine that has been proven to work, there is no cure. Treatment of COVID-19 patients will largely remain supportive — with oxygen therapy. As pneumonia progresses and shortness of breath and hypoxemia ensues, oxygen treatment will be mainly delivered through nasal cannulas, then facemasks, then 100% non-rebreathers, then non-invasive ventilation (NIV) via CPAP or BiPAPs. If the patient continues to deteriorate, tire out and spiral down into respiratory failure, the last resort is endotracheal intubation and oxygenation through a ventilator. This is when we anesthesiologists are called in.
Our role as airway management experts is to intubate. We are the ones who will come when patients are at the end of their rope. In non-emergencies, standard intubation is straightforward, especially in patients with good airway anatomy. You have a relaxed, non-distressed patient that you will anesthetize smoothly in a controlled step-wise manner: Pre-oxygenation, hypnotic, muscle relaxant, bag-mask ventilation, laryngoscopy, endotracheal tube, ventilator, anesthesia.
Intubation in an emergency, when a COVID-19 patient is in extremis, is totally different. You have a patient who is in severe respiratory distress, anxious, and severely hypoxic. The clinical picture is like someone in status asthmaticus. You will see the patient desperately gasping for air, in pain, in distress, and with terror in his/her eyes — a heartbreaking sight. Add to this scenario your own fear, knowing the risk you face because you will be moving in close, mere inches from the patient’s mouth and nose that are laden with the highest viral load.
To start with, the NIV being administered as a means of delivering oxygen is already generating aerosols around your patient. As you approach, expect that the air around you is already dense with a mist of viral aerosols, especially if you are situated in a non-negative pressure room that does not suck the dangerous mist out. Endotracheal intubation is an aerosol generating procedure. In the process of intubation — when you bag-mask and when your patient bucks or coughs — you are at risk of getting showered with virus straight to your face. This is akin to looking straight down the barrel of a locked and loaded shotgun.
Most people get infected by accidentally getting fomites rubbed over their eyes, nose or mouth. This is exposure with a small viral load, which oftentimes is possible for the body to overcome. For most infected persons, as you might have heard, about 80%-85% will recover. It is a different story if you get directly hit by a massive viral load in your face, such as during intubation. If you get infected this way, this will not be easy to overcome, even if you are in the peak of baseline health. This is probably why infected healthcare providers who deal very closely with their patients — ER docs, ENT docs, ophthalmologists, pulmonologists and anesthesiologists — have such a high mortality rate, because they often get infected with a high load of virus that gets shot straight into their faces. So, understand the risk we have to face and the fear that we have to overcome as anesthesiologists when we try to rescue our COVID-19 patients. Sometimes I question if it is even worth the risk if the current outcome is already grim for patients who get intubated. Every hospital setting is different, but ours does not have the best outcomes after intubation because we generally have sicker patients who have a lot of co-morbidities. Currently at our institution, only 10%-15% of those who get intubated make it out, get extubated and recover fully. Most succumb after three or four days on the ventilator. This is why we do the intubation in the COVID-19 patient differently. We modify our intubation technique to prevent any aerosol generation as much as possible. We do this by avoiding bag-masking or ambu-bagging without a HEPA filter, by making sure the patient is completely paralyzed with muscle relaxant so he/she does not cough during intubation, by using video-laryngoscopy so that we can avoid facing the patient’s mouth directly — and, of course, by relying on level 4 PPE.
Thank God that currently we are good with our supplies of PPE. But I worry with all this talk about PPE shortages that we will finally run out; we can only continue with our work while our PPE supplies last.
So, friends, this is the cross that we anesthesiologists have to bear this Good Friday. But alas, recognize that our patients carry a heavier cross! Please do not be a patient. Follow the guidelines! I know most of you already are. I just want to re-emphasize this because I don’t want to be in a position where I will need to intubate you.
Praying for everybody’s health and safety.
Dennis Dimaculangan, M.D.
SUNY-Downstate Medical Center
Until we have a vaccine, an antiviral, plasma antibodies, hydroxychloroquine that has been proven to work, there is no cure. Treatment of COVID-19 patients will largely remain supportive — with oxygen therapy. As pneumonia progresses and shortness of breath and hypoxemia ensues, oxygen treatment will be mainly delivered through nasal cannulas, then facemasks, then 100% non-rebreathers, then non-invasive ventilation (NIV) via CPAP or BiPAPs. If the patient continues to deteriorate, tire out and spiral down into respiratory failure, the last resort is endotracheal intubation and oxygenation through a ventilator. This is when we anesthesiologists are called in.
Our role as airway management experts is to intubate. We are the ones who will come when patients are at the end of their rope. In non-emergencies, standard intubation is straightforward, especially in patients with good airway anatomy. You have a relaxed, non-distressed patient that you will anesthetize smoothly in a controlled step-wise manner: Pre-oxygenation, hypnotic, muscle relaxant, bag-mask ventilation, laryngoscopy, endotracheal tube, ventilator, anesthesia.
Intubation in an emergency, when a COVID-19 patient is in extremis, is totally different. You have a patient who is in severe respiratory distress, anxious, and severely hypoxic. The clinical picture is like someone in status asthmaticus. You will see the patient desperately gasping for air, in pain, in distress, and with terror in his/her eyes — a heartbreaking sight. Add to this scenario your own fear, knowing the risk you face because you will be moving in close, mere inches from the patient’s mouth and nose that are laden with the highest viral load.
To start with, the NIV being administered as a means of delivering oxygen is already generating aerosols around your patient. As you approach, expect that the air around you is already dense with a mist of viral aerosols, especially if you are situated in a non-negative pressure room that does not suck the dangerous mist out. Endotracheal intubation is an aerosol generating procedure. In the process of intubation — when you bag-mask and when your patient bucks or coughs — you are at risk of getting showered with virus straight to your face. This is akin to looking straight down the barrel of a locked and loaded shotgun.
Most people get infected by accidentally getting fomites rubbed over their eyes, nose or mouth. This is exposure with a small viral load, which oftentimes is possible for the body to overcome. For most infected persons, as you might have heard, about 80%-85% will recover. It is a different story if you get directly hit by a massive viral load in your face, such as during intubation. If you get infected this way, this will not be easy to overcome, even if you are in the peak of baseline health. This is probably why infected healthcare providers who deal very closely with their patients — ER docs, ENT docs, ophthalmologists, pulmonologists and anesthesiologists — have such a high mortality rate, because they often get infected with a high load of virus that gets shot straight into their faces. So, understand the risk we have to face and the fear that we have to overcome as anesthesiologists when we try to rescue our COVID-19 patients. Sometimes I question if it is even worth the risk if the current outcome is already grim for patients who get intubated. Every hospital setting is different, but ours does not have the best outcomes after intubation because we generally have sicker patients who have a lot of co-morbidities. Currently at our institution, only 10%-15% of those who get intubated make it out, get extubated and recover fully. Most succumb after three or four days on the ventilator. This is why we do the intubation in the COVID-19 patient differently. We modify our intubation technique to prevent any aerosol generation as much as possible. We do this by avoiding bag-masking or ambu-bagging without a HEPA filter, by making sure the patient is completely paralyzed with muscle relaxant so he/she does not cough during intubation, by using video-laryngoscopy so that we can avoid facing the patient’s mouth directly — and, of course, by relying on level 4 PPE.
Thank God that currently we are good with our supplies of PPE. But I worry with all this talk about PPE shortages that we will finally run out; we can only continue with our work while our PPE supplies last.
So, friends, this is the cross that we anesthesiologists have to bear this Good Friday. But alas, recognize that our patients carry a heavier cross! Please do not be a patient. Follow the guidelines! I know most of you already are. I just want to re-emphasize this because I don’t want to be in a position where I will need to intubate you.
Praying for everybody’s health and safety.
Dennis Dimaculangan, M.D.
SUNY-Downstate Medical Center
Photos submitted by Tazeen Beg, M.D. - Stony Brook University Medical Center
NewYork-Presbyterian/Weill Cornell,
submitted by Shana Hill, M.D.
The anesthesiology airway team at New York-Presbyterian Hospital/Weill Cornell Medicine has taken on management of all COVID-19 patient airway-related procedures across the hospital.
We travel to the ED, all the ICUs, and the COVID wards to perform emergency and urgent intubations and endotracheal tube exchanges, as well as elective tracheostomies. Our team of anesthesiologists, CRNAs, and anesthesia techs has been integral to the expert management of these patients. We are grateful for our amazing team and the collaboration we have had with the emergency department and intensive care teams! |
Mount Sinai Health System
submitted by Jonathan Gal, M.D., FASA
Dr. Zevy Hamburger, is a COVID-19 survivor who has since been covering Mt. Sinai's COVID ICUs, participating on the intubation team, helping with the proning team, and even donating his own plasma to help treat patients with his COVID antibodies.
He put together a 13 minute YouTube video. He has also been interviewed and spotlighted on ABC Nightly News, Good Morning America, CNN and MSNBC.
Other Mt. Sinai anesthesiologists have helped advise and facilitate NASA's attempts at creating a new COVID-19 ventilator that can more easily be used throughout the world and during these abnormal times when ventilators may be of short supply.
Drs. Matt Levin, Dan Katz, Anjan Shah, Ronak Shah, Cheuk Lin (Salina) Lai, and George Zhou all helped with this process.
The same group also helped to innovate how to potentially ventilate two patients with one ventilator. They were featured on CBS Morning News, and were included in the NYT feature on Mount Sinai.
He put together a 13 minute YouTube video. He has also been interviewed and spotlighted on ABC Nightly News, Good Morning America, CNN and MSNBC.
Other Mt. Sinai anesthesiologists have helped advise and facilitate NASA's attempts at creating a new COVID-19 ventilator that can more easily be used throughout the world and during these abnormal times when ventilators may be of short supply.
Drs. Matt Levin, Dan Katz, Anjan Shah, Ronak Shah, Cheuk Lin (Salina) Lai, and George Zhou all helped with this process.
The same group also helped to innovate how to potentially ventilate two patients with one ventilator. They were featured on CBS Morning News, and were included in the NYT feature on Mount Sinai.