Lessons learned during New York’s COVID-19 Crisis

The UANA board requested I share my experiences at Bellevue Hospital in New York City during the COVID-19 crisis including lessons learned and suggestions to streamline response in the future. I hope this summary can answer questions and assist UANA members if we experience a similar situation.

I’d like to thank my family and anesthesia partners for supporting me and allowing me this opportunity.

Any information I present is purely my opinion and is not representative of or approved by Bellevue Hospital, New York HHC, New York City or New York State government. Any examples, discussion or data is aggregated and does not reflect a specific patient or situation and is presented for educational purposes only.

The Beginning

My experience began when I contacted a recruiter Monday evening, April 6. I obtained emergency privileges Friday April 10, flew to New York City on 1 hours’ notice and reported for work 7 am Saturday April 11. Mandatory HIPPA and Sexual Harassment training, etc. (I could practice without a New York license during an emergency but JCAHO requirements are inviolate) as well as ID badges, computer access, etc. took up the morning. I reported to the respiratory department noon April 11.

I requested assignment to any of the OR, intubation, airway management, Central IV’s, arterial lines or “Proning” teams but all positions were covered by Anesthesiology Residents and local Physician Anesthesiologists. I was actually told that as a CRNA I was less qualified than a resident, later experiences showed that opinion to be optimistic (I’m still not sure how 20+ years of intubating experience makes one less qualified compared to a novice resident with much less training, a twentieth the experience but four times my confidence; I and other CRNA’s in non-anesthesia roles repeatedly assisted residents and when they had difficulty managing airways). As the traditional anesthesia needs were currently filled I was asked to assist the overwhelmed Respiratory Department because “you work with ventilators, this should be easy”. This assumption, like many others, was very optimistic.  I know my anesthesia machine vent but there was a large learning curve to fill the RT job and I have a new respect for the breadth of knowledge and experience the RT’s I worked with demonstrated.

Planning

The leadership at Bellevue made several good choices anticipating the surge of patients. They knew they’d need the maximum number of ICU beds (they started with 48 beds in the main ICU’s and a 16 bay PACU) and so made an ICU wherever there was un-interruptible power and adequate oxygen. Where possible they made the room negative pressure by taking out a window and running a HEPA fan through vented plywood. Other areas such as the Endoscopy unit, Ambulatory care and a section of the Emergency Department were “hot zones” where providers donned protective gear and did not leave during their shift, handing off specimens and supplies to “clean” assistants outside the unit. They also double bunked the existing ICU rooms using transport monitors, etc. This required extra vigilance as the ventilator or monitor nearest the patient did not always correspond to that patient. We were careful to label each vent, monitor and patient in a shared ICU room as “A” or “Z” to reduce confusion however it was a constant struggle to avoid tripping over cables, IV lines and other equipment while wearing a mask that restricted your lower peripheral vision in a room built to house one bed.

The Emergency Department triaged and rapid tested all incoming patients in separate tents (one suspected COVID, one not suspected) outside the facility before the patients could enter the hospital. Once inside all patients, providers and staff were expected to wear masks and practice social distancing. Staff screened anyone entering the facility for fevers and no visitors were allowed, there were reports that visitors infected a patient who then infected a provider, that provider later died.  About 87% of patients coming for non COVID complaints were asymptomatic COVID positive giving weight to the theory that the “herd immunity” is much further developed than previously thought.

The medical leadership also worked closely with administration, local and state government to minimize disruption. This led to emergency proclamations that temporary providers could work without a New York license and that providers could only be sued for obvious and gross negligence, etc. Administration was helpful by doing whatever the physicians deemed necessary rather than a more typical collaboration where other concerns had a priority.  This resulted in rapid creation of over 150 ICU Beds as well as multiple acute care COVID units.

I was military trained and spent over 3 years at the University of Maryland Medical System Shock-Trauma Center in Baltimore before moving to Utah. This experience helped me to be flexible and use whatever equipment and supplies were available, I trained often to deal with mass casualty situations and I spent 3+ years dealing with very ill and critical patients. I thought I’d be prepared but was completely wrong, New York was worse than anything I ever planned for or experienced. I think all of us could do a good job managing a mass casualty situation, what happens if that mass casualty surge happens 12 times a day, 7 days a week for 6+ weeks? Add in crowded conditions, inadequate and limited supplies, critically short staffing, hot and clumsy protective gear that impeded movement and limited vision, and fear of contracting the disease and it became a never ending horror movie.

My Experience

When I arrived at the RT department that Saturday I assisted a RT who’d been working overtime since March 16 (She’d been on for 48-60 hours a week X 5 weeks, she’d made the choice to stay in Manhattan and not risk infecting her family. So she worked her butt off in a near overwhelming situation 60 hours a week then went “home” to a hotel and only saw her kids via FaceTime).  There was no time for orientation, I was immediately tasked to set up a ventilator for a patient that failed CPAP and needed emergent intubation. I literally had to ask where the on switch was on the ventilator, I then stumbled through settings and alarms and felt completely inadequate. First Key Point- Don’t assume you’ll be prepared to take on a new role, practice with the equipment before the feces hit the rotary impellor. That Saturday four RT’s covered 120 ventilators, 50 or so CPAP/ BIPAP and high flow nasal cannula patients responded to codes and airway emergencies spread out over 20 floors.

The high patient loads that led to double bunking in ICU rooms and open bay ersatz ICU wards led to compromises in care that would be unacceptable during “normal” times; several times a more alert patient saw their roommate die as there weren’t any open rooms. We were often forced to house men and women patients in the same room; there wasn’t time or resources to separate genders when a patient needed an ICU bed. Second Key Point: Pandemic rules are like wartime rules, you don’t have time/resources to follow your typical “Peacetime” routine or standard of care. I was often so busy that my “care” was a quick peek through the window as I ran to another emergency just to make sure the patient was still alive, the ICU nurses kept the IV pumps outside the rooms to allow setting changes or hang new bags without using scarce PPE leading to IV lines and manifolds on the floor contrary to infection control requirements, etc. I saw a video from the friend of an NP helping in New York criticizing the care during the crisis. On its face the claims in the video seem unconscionable and unethical. Having worked during this time I understood the rationale behind some of the choices being criticized, the NP was still judging using non-crisis rules and procedures. Early we did intubate instead of trialing CPAP in an effort to reduce aerosolizing virus, however as ventilators and ICUs beds ran short we used CPAP more often and worried less about aerosolization.

Third Key Point: Be creative and flexible during a crisis. We used no or minimal CXR’s after intubation to avoid contaminating X-ray machines or the likely damage when a large machine was brought into a crowded room, and we didn’t listen to breath sounds after intubation to avoid contamination by putting our faces near the patient’s airway. We relied on visualization of cuff 2-3 cm past vocal cords and ETCO2 to verify placement and called it good. Positive End Expiratory Pressure (PEEP) valves were on back order for most of the crisis, during emergency ambu bagging I often provided make shift PEEP by occluding the expiratory valve with my gloved hand at the end of exhalation. Others stretched the finger from a nitrile glove over the expiratory valve for PEEP with some success.

All of us instinctively respond immediately to alarms, patient’s deterioration, and codes. Fourth Key Point: There are no emergencies in a pandemic. It was a mental challenge to defy years of training and expectations to take the time to correctly don PPE before entering a crashing patient’s room; I had to remember if I became ill more than that patient would suffer harm because I wouldn’t be there to assist.

That initial Saturday from noon until 1900 we had countless codes (peak was 8 airway emergencies/ codes between 1300 & 1630, I lost track of the total number for the day), we literally ran from crisis to crisis with no time to plan, only react. Later, many of the codes occurred due to “COVID cement” blocking the ETT. I believe high flows in the FEMA supplied LTV vents that used an inadequate HME as well as a result of the disease process itself caused these blockages. Deciding to exchange ETT’s was not an easy decision, the patients had no pulmonary reserve and couldn’t tolerate even brief periods of apnea.

Fifth Key Point: Leadership needs to be proactive not reactive. The people best suited to determine what was working, what needed to change and the most effective use of resources were usually too busy caring for patients to make those critical decisions. It seemed everyone had no time to anticipate, only to react. Make sure you have an experienced and qualified leader that isn’t too busy or exhausted from caring for patients to be able to sit back and make strategic decisions.

I was constantly mentally and physically exhausted, I estimate that I walked/ran 7-10 miles that first day responding to emergencies. Sixth Key Point: a pandemic taxes physical and mental energy. The community and city government did what they could to show support and appreciation, I rarely bought lunch as local restaurants and the city government donated food daily. A local grocery store was closing but allowed me in when they saw my scrubs and ID. The city would play New York, New York and make noise, sirens, etc. at 7pm every day to say thanks. The hospital would play “Don’t Stop Believin’ by Journey” whenever the ICU discharged a patient, and “New York” when a COVID patient was discharged home. Hospital leadership also opened a “respite room” with snacks and lounge chairs staffed by volunteer clergy where overwhelmed providers could take a moment to recharge. All made the incredible stress of the situation a little less burdensome.

Throughout the crisis we gradually obtained more providers including 6 CRNAs and several dozen RT’s. It’s been much easier to function with 10-13 providers per shift as well as a gradual decline in patient acuity making the job easier. When I left we were at 65 combined vents and CPAP, High Flow Nasal Cannula, etc. as most of the patients either recovered or more likely, died.

Seventh Key Point: Pandemic manning is 150-200% of expected. Staff may get sick and all were exhausted, the patient load and acuity were much higher than expected, and you need extra help like assistants to transfer labs and supplies into/out of the hot zone, etc. Staffing requirements are always more than you anticipate. It took five weeks to obtain the needed extra help; anticipate the need and staff early so you’re only a few weeks rather than months behind. There was no effort to economize at first, fortunately FEMA provided equipment and money that allowed leadership to focus on care only.

Most of the patients I initially cared for were intubated, about 50% were on some type of dialysis and we constantly used the hospital’s limited ECMO capability. We had ten Nitric Oxide machines in frequent use as well, as soon as one patient was weaned off (or expired) we rapidly cleaned the system and started it on another patient. Supplies were ALWAYS in short supply and we occasionally had to decide who got the lifesaving device, it was triage in action.

Eighth Key Point: Supplies evaporate; no matter how much you think you have they’re not enough. Think holistically, it’s not enough to have the vents and circuits, do you have enough drugs and disposable IV tubing, IV pumps, central lines, transducers, etc.? What about ETT holders (we’re still short on this necessary disposable and have daily issues with tubes dislodged because the old ETT holders no longer reliably keep the tube secure and no one seems willing to use other methods)? Most of Bellevue’s fleet of versatile Puritan-Bennet ventilators were useless because they couldn’t obtain a unique filter necessary to make the vents work.  We had adequate amounts of circuits and other ancillary supplies but the lack of filters forced us to use the less versatile LTV vents supplied by FEMA. Despite pre-crisis planning we rapidly ran out of cheap disposable PPE, we ended up using expensive sterile surgical gowns for PPE.

The hospital was overwhelmed despite excellent planning leaving fewer resources to deal with non-COVID illnesses and trauma. Local residents feared contracting COVID if they came to the hospital so put off necessary care; no one knows how many chest pain, strokes or acute abdomens delayed coming in for fear of contracting COVID and suffered unnecessary morbidity. As one provider told me “Don’t get sick right now, we just can’t take care of you”. I witnessed a lot of fear of contagion in the staff and patients of the hospital as well as in the community, most of it stoked by local and national news.  Ninth Key Point: Expect fear and misunderstanding.

Anesthesia Specific

We found that patients in the early stages of COVID respiratory failure have radically reduced pulmonary reserves; despite aggressive pre-oxygenation prior to intubation (no ventilating to reduce aerosols) O2 Sats would drop to the 30s after 15-20 seconds of apnea during intubation. Patients in the late stages needing intubation (usually because of inadvertent extubation, often within minutes of being turned prone and the tube dislodged, also for the occasional tube exchange) will drop immediately and may take hours to return to the 80s, if they ever do.  Therefore the most skilled provider should intubate as rapidly as possible using a Glidescope or other video intubation device that keeps the provider as far away from the aerosols as possible. We did not use intubation boxes despite their availability, you just don’t have enough time to locate and set them up. They were also fragile, I saw several broken boxes in the corners of the ICU. Tenth Key Point: Use your most competent provider to rapidly intubate while maintaining a calm and controlled demeanor.

You also need your best and most experienced providers rounding on your patients. A hospital in the Bronx had Family Practice Residents covering the ICU overnight, they were blamed for a patient’s death because they made incorrect and dangerous vent settings. The residents admitted that they were unfamiliar with the ventilators and did not/could not get assistance.

Ventilated COVID patients required five to six times greater sedation compared to “normal” septic patients. We used a combination of fentanyl, midazolam, dexometomidine, and propofol depending on what was available. Vasopressor of choice was Levophed with Vasopressin as needed. We used paralytics sparingly and almost always Cis-atricurium due to the prevalent acute renal failure. I didn’t see many patients receiving Remdesivir, Hydroxychloraquine, Azithromycin or other proposed treatments, I was told the studies were equivocal as to efficacy.  We did use IL-1 and IL-6 blockers with some effect. We also used proning on the worst cases but it’s a difficult decision, they used a normal bed without chest rolls, donut pillows, etc. and have a high incidence of ETT dislodgement. The proning team used 5-6 athletic providers to position the patient.

CRNA Utilization

As stated Bellevue used their permanent staff and residents to cover OR cases, Central/ Arterial Line and Airway/Intubation Teams. Volunteer Physician Anesthesiologists and CRNA’s assisted the Critical Care/ Intensivists, were resources for IV access and to the ward teams and as in my case, assisted with vents and RT. I met only one CRNA who worked a bedside nursing position. I did feel underutilized, I don’t know how my experience would have been if I’d been assigned to a non-teaching hospital with fewer residents and higher critical care and advanced practice needs. Final Point: Don’t let bias and conventional thinking keep you from performing to your level of training. With hindsight I should have asked to be assigned to another hospital where I could have made a greater impact, but like Point Five I was caught up in reacting and not being proactive. Make plans now with administration and medical leadership to have a defined role that will utilize your advanced and specialized skills and knowledge.

The Final Chapter

Bellevue is finally on the downslope of the crisis with fewer admissions and the initial mass of patients have either recovered or expired (>80% of intubated patients did not survive). I returned to Utah May 2 after three weeks in NYC, I felt justified leaving as the RT department is fully staffed, the hospital census and acuity is manageable and my group needs my assistance as we prepare to resume elective surgeries. I learned a lot, the primary lesson is: don’t let this occur to our communities.

In summary the lessons learned (in no particular priority):

1. Don’t assume you’ll be prepared to take on a new role, practice with the equipment before the feces hit the rotary impellor
2. Pandemic rules are like wartime rules, you don’t have time/resources to follow your typical “Peacetime” routine or standard of care
3. Be flexible and creative i.e. faux PEEP valve using your hand and ambu bag
4. There are no emergencies in a pandemic
5. Leadership needs to be proactive not reactive
6. Pandemics task physical and mental fitness
7. Manning needs are 150-200% of expected
8. Supplies evaporate, no matter how much you think you have they’re not enough
9. Expect fear and misunderstanding
10. Use your most competent provider to intubate while maintaining a calm and controlled demeanor
11. Don’t let bias and conventional thinking keep you from performing to your level of training
    I hope that I was able to provide a little insight into the difficulty a pandemic will cause and give some suggestions on how we can best meet this and future challenges.