It was a Saturday in mid March. I sat down in the back of the IR control room, and I began dictating chest radiographs from the ER. The first one demonstrated subtle hazy peripheral opacities. It was not garden variety bacterial pneumonia. I called the ER attending, “I am concerned this is COVID-19.” The next chest radiograph showed peripheral, ill-defined, bilateral airspace opacities. I called the ER
attending again. One after the other, I began to feel like a broken record with my dictations, and phone calls. On CTs of the abdomen and pelvis performed to rule out nephrolithiasis, diverticulitis, etc… I was seeing bilateral, peripheral, ground glass opacities in patients who were otherwise asymptomatic from a respiratory perspective. I picked up the phone again: “No stone, no diverticulitis, but I’m worried they have COVID-19.”
Prior to this, we had seen probably fewer than five suspicious cases at my hospital. On Monday, I followed up the COVID testing for those patients. They were all positive. The floodgates had opened, and COVID-19 came charging through.
Our hospital, one of NYC’s public hospitals and a level 1 trauma centre, was transformed. Normally empty stretchers lining the halls and back corridors of the ER soon overflowed with COVID-19 patients. The public health system quickly nearly tripled its existing ICU capacity. US Army doctors, nurses, and physician assistants answered the call of duty, and helped support us through this crisis by helping staff some of the new ICUs. Elective surgeries were postponed. We postponed doing elective IR cases.
In March, prior to the surge, my partner and I would go to the ICU and place central venous catheters and arterial lines on patients to help ease the burden on the ICU staff. With a program of four radiology residents per year, one resident was assigned to night float, and four covered various rotations simultaneously.
The other residents stayed at home and were on backup in case someone became ill. Many diagnostic radiology attendings obtained home access and started to report remotely. By the beginning of April, all of our radiology residents were redeployed to internal medicine.
As the ICU volumes increased, my IR partners and I, with a handful of ESIR (early specialization in IR) residents, formed a procedure team. We were running all over the hospital, from the ER to the ‘wards’ and ICUs to perform all kinds of venous access procedures and place arterial lines. COVID-19 started taking out people’s kidneys left and right.
The Nephrology service stopped placing temporary dialysis catheters at the beginning of the pandemic, and the procedure team took over that responsibility as well. The number of patients requiring temporary dialysis catheter placement surged exponentially to the point where we ran out of catheters in the entire hospital.
With no glimmer of hope for imminent improvement in their AKI, many of these COVID-19 patients subsequently required Permacath placement. With only positive pressure IR suites, these patients could not be brought down to IR. As such, they had to be performed in the one negative pressure OR with a C-arm. If a patient was here long enough, odds were they needed one of the ‘usual’ IR procedures, such as a pleural drain, abscess drain, etc. Anything capable of being performed under CT-guidance was done in CT, as it was a neutral pressure room.
During the height of the pandemic, we continued to perform the occasional urgent biopsy or portacath placement for urgent chemotherapy for outpatients, and we kept our pre- and post-procedural area a ‘cold’ zone, free of COVID-19. When we had a patient bleeding to death requiring emergent angiography/embolization who was either COVID-19 positive or under investigation, we performed the case in our positive pressure IR suite, and hoped we would not get sick.
The PPE situation felt dire due to the global supply chain challenges. In the first week of March, we had run out of our regular supply of N95s that we have in IR, and one of the IR nurses and myself went to procure more from another department as we anticipated needing them for a potential procedure on a patient on airborne precautions.
Later that day, they were taken away. Due to the system-wide PPE conservation practices in response to potential shortages, we were told that if we needed a mask we would have to sign one out for a specific procedure, and demonstrate that the patient was on airborne precautions in order to obtain one. Once the conservation efforts were in place, all PPE became centralized within a command center housed outside the ER. From the command center, you could see the refrigerated trucks, which housed the deceased.
Once per week, we were given a brown paper lunch bag, which contained an N-95 mask and a standard surgical mask, but no sandwich. Following CDC guidance, we were asked to reuse the N-95 mask unless it became visibly soiled or broken. It felt as though we were being sent in to battle without armor or weaponry. We began wearing paper scrubs.
The scariest moment for me was when I was in the ICU placing a bedside dialysis catheter. The intubated patient started to move around, and they managed to disconnect their ventilator. Unfortunately, I didn’t realize they had disconnected it, as it was under the drape right next to the opening with the sterile field. An alarm eventually went off a while later, and we alerted the ICU attending to the alarm and dropping SpO2. All the while, unbeknownst to me, I stood in the line of fire as the viral particles in the tube were being emitted.
Almost four weeks ago, I underwent serology testing. It resulted negative. While it would have been comforting to have antibodies for COVID-19, I am reassured by the fact that PPE actually works. But, it’s a matter of having a sufficient supply. Recently, I went to procure an N95 mask, and there was a giant sign that read “STOP! We do not have regular N95s at the moment. Corporate aware!” A supply arrived later that day.
A number of doctors and nurses became very sick at the height of the pandemic. Some died. Morale across the city was very low. The city that never sleeps went for a nap, and shortly after, it went into complete hibernation.
There was a mass exodus of people fleeing the city. Grocery stores and pharmacies reduced their hours, and limited the number of people permitted inside. Grocery deliveries were impossible to garner. Buying food and obtaining essential items became difficult, as everything was closed by the time most of us would get home from work. Michael Bloomberg’s Bloomberg Philanthropies donated millions of dollars to fund World Central Kitchen, which provided meals for workers at the hospital. After spending a long day at the hospital, I would return to a desolate, grey, cloud-filled sky towering over lower Manhattan, its sidewalks flanked by homeless people and garbage bags. Restaurant and bar windows were boarded up with plywood.
There have been over 50,000 people hospitalized with COVID-19 in NYC. The municipal death toll topped 20,000.* Given the mortality rate was 76.4% and 97.2% for patients receiving mechanical ventilation aged 18-65 and 65 and older, respectively, many of the people I encountered and treated sadly contribute to that gut-wrenching statistic.**
The hospital started playing “Fight Song” by Rachel Platten overhead every time a patient was extubated. For a while, we were hearing the song very often, 5 to 6 times per day. People would cheer, clap, or let out a sigh of relief every time it was heard.
By mid-May, over 700 COVID-19 patients had been discharged from my hospital, and over 6,000 across the NYC public hospital system. NYC’s daily death rate is finally in the double digits – a dramatic improvement from what it once was topping over 800. Pediatric patients have since returned, and a number of the converted wards have been reconverted back to ‘cold’ non-COVID-19 units. Elective surgery and elective IR procedures are slowly resuming. People are returning to NYC, filling parks, and running along the East and Hudson Rivers.
Some people socially distance appropriately and wear masks, while many others do not. Non-healthcare workers press for society to reopen. Meanwhile, those of us who on the front lines anxiously await the potential second wave. We fear the fate of those who remain intubated and admitted.
But, on the bright side, one of our hospital’s nurses recently was discharged after battling COVID-19. The clip even made it to CNN. She was cheered on as she left the hospital, and finally had a breath of fresh air. For the first time in a long time, my tears were filled with joy, and some hope, instead of despair. The sun has finally broken through the clouds, and is starting to shine through.
Dr. Rebecca Zener
Attending Interventional and Diagnostic Radiologist, NYC Health and Hospitals
References
*https://www1.nyc.gov/site/doh/covid/covid-19-data.page
**Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA 2020;323:2052-9.