As the days progressed: Reflections from volunteering in the COVID-19 ICU
"Faculty are now being asked to volunteer for redeployment to the COVID-19 ICU."
This was in the email I received on a Saturday morning in mid-April. We had been warned that faculty redeployment could happen. We had been watching New York. The Maryland curve was a bit further behind but still heading in the same unfortunate direction. So I signed up. I had a long talk with my husband, who is also a surgeon. I kissed and snuggled my children and planned my decontamination corner of the garage. I did my last telemedicine visits, rearranged my call obligations, and cooked a lot of food for my family.
Let me be clear: I'm a reconstructive breast surgeon at Johns Hopkins Medicine; I do microsurgery and body contouring, and I direct our resident cosmetic clinic. At Johns Hopkins, we have world-renowned internal medicine and pulmonary programs. Sure, I was once a burn and surgical critical-care Fellow. Though I'm board-certified in critical care and general surgery, let's be honest: I haven't been in an ICU in more than 10 years. I wasn't sure what I could offer the team, but I figured if they were tapping into the plastic surgery faculty, someone higher than me had a plan. I reviewed the prep material provided about COVID-related laboratory derangements and protocols we were following. I reviewed vasopressors and vent modalities for ARDS, but overall, I felt rather unprepared. I had been reading the moving daily updates from NewYork-Presbyterian/Columbia University Medical Center by Craig Smith, MD, and I was scared.
Names, protocols change
Psychiatry intern. Pediatrics chief resident. Urology resident. Pulmonary Fellow. Med- Peds Fellow. Genetics resident. This was my team. I couldn't believe it. We were like the Benetton of physicians at an academic center. Many had volunteered, some were "volun-told." We would work two, 12-day cycles: Four days of 12-hour shifts, days, nights, off. The unit featured the same diverse environment. CRNAs as ICU nurses, pediatric RTs working adult ventilators, surgery nurses as safety officers making sure we donned and doffed our PAPRs properly, saving us from ourselves and protecting the entire team.
The unit was a biodome with one entrance and one exit. Everyone was in PAPRs or N95 and face shields. Each room had a patient – all of them ICU status. This was one of eight inpatient units converted to an ICU. It had been open for five weeks.
My first time on the unit, I thought I had made a mistake. The PAPR is claustrophobic. It is loud. There is limited peripheral vision. I was awkward and stiff. I washed my hands. Donning two sets of gloves and a gown, I followed the ICU Fellow into a room, memorizing the steps to protect myself and my family. The unit was so loud. I wondered how I would know if my battery wore out. I was afraid to touch anything. I did not know a soul. I tried to calm my breathing, as I wondered what I was doing there. How was everyone else so calm?
Then I realized that despite all the awkward clothing and precautions, it was an ICU – just like the ones in which I'd trained. Most patients were ventilated. Some were prone and paralyzed, others were weaning and having usual post-ICU deconditioning, delirium and infections. Many had thromboembolic events and several were on CVVHD. The root cause for all was COVID-19. What they shared was the perplexing physiology common to COVID-19 infection, but the phenotypes varied. Our Fellows and attendings have more experience with specific COVID pathophysiology, but even their experience is limited.
As the days progressed, I realized that these are the same diagnoses that have been treated in ICUs since I was a resident. We are treating ARDS, liver failure, NSTEMI, atrial fibrillation, GI bleeds, renal failure, seizure disorders, diabetes and DIC. Although critical-care principles remain largely the same, some of the names and protocols have changed. RASS scores have replaced arousal scores. We didn't do bronchoscopy. Nobody gets a PA catheter anymore. I gained a new respect for pulmonary emboli, right heart failure and inhaled nitrous oxide. We extubated a few patients who progressed to the floor. Some we reintubated and started over. Others said goodbye with their families on Zoom.
Each day I got over my own insecurities about being out of my element. It's not so different from my first telemedicine visits – it's awkward, but I got the hang of it. I also realized that everyone was in training. The stepdown nurses were paired with MICU nurses who would supervise them. The ratio adjusted from 1:2 to 1:3 to 1:4 as the weeks progressed and the nurses got up to speed. I supervised a few residents putting in A-lines and central lines – turns out I still remember how to do that, but they showed me how to do it with the ultrasound. I learned about point-of-care-ultrasound (POCUS) and wondered how much easier residency would have been with this modality. Focused Abdominal Sonography for Trauma (FAST) was just becoming mainstream when I trained. I gave my opinion on abdominal CTs, examined patients and tried really hard not to say, "When I was a resident…"
Short-term and long-term change
I'm in awe of the professionalism I saw around me every day. I watched the proning team gently and carefully switch one of our sickest patients from supine to prone. They gently protected her ears, padded her ulnar nerve, placed her in swimmer's position every two hours. The residents on my team called the families every day with updates. They played videos on their cellphones from families to the ventilated patients. The senior respiratory technician made constant circles checking on vents, other RTs, the doctors. The psychiatry resident spent more than a half-hour calming one hypoxic, non-intubated patient with severe anxiety about her sat monitor. A patient passed away surrounded by his family singing to him via Zoom.
As a group, we offered whatever skills any of us could. We made jokes about our shared experiences as medical students. The residents gracefully configured my EPIC settings so I could easily access data for rounds. I explained the long-term sequelae of chronic hand pain and dysfunction from improper A-line placement and showed everyone how to do a proper Allen's test with a Doppler. Every other day, there was a comment from one of the senior Fellows, attendings or residents about how great it would be if all our teams were this multidisciplinary. I wonder how our culture will change after this pandemic is over?
There seemed to be waves of different cohorts of patients. The first group were people who had traveled and acquired the virus before we began to shelter in place. The community-acquired cases came next and we had an influx of transfers from other centers. They were older and sicker – often nursing-home residents – patients with other co-morbidities. As I finished my tour, we seemed to have more patients from our local immigrant communities. Some who had been sheltering in place, but many essential workers or unemployed. They were often very sick, clearly suffering at home until beyond when they should have sought care. Most are non-English speaking, many without contacts to call.
Toward the end of my time on the unit, I appreciated changes in infrastructure the institution made as we adapt to the changing landscape of the pandemic. We are well-staffed. I wasn't needed on nights. We started to do tracheostomies on some of the longer-ventilated patients. Our RTs configured a trach collar with T-tubing and filters to prevent aerosolization and allow for humidified oxygen administration. We are beginning to convert some of the COVID-19 units back to non-COVID units.
As plastic surgeons, we have special skills. We can correct congenital abnormalities, stabilize fractures, reconstruct defects and enhance appearances. We restore form and function. We contour and augment. We improve patients' quality of life. Few of these skills seem necessary or important in the COVID-19 pandemic. Some of us feel useless. We are unsure about our futures, our finances and the livelihood of our employees. Small-business loans, furloughs and how to acquire PPE became the new dialogue. We feel disconnected from our patients. The forward progress of our research efforts and innovations seem impossible. We are not essential. Our surgeries are elective and postponed indefinitely. We are stuck in a spiral of never-ending Zoom meetings, telemedicine visits and cancelled cases with no end in sight. The emotional toll on all of us is significant.
None of us know when this pandemic will end or what our future holds. At the time of writing this, we still haven't begun performing elective surgery again. I suspect we will be asked to be re-deployed again. Our curve in Maryland is flattening. It wasn't as bad as we feared. We were prepared – or maybe we were just lucky. Our governor was aggressive early with social distancing and closing non-essential businesses. Johns Hopkins was probably better prepared than most centers and we had the advantage of a head start. Many know and have used the online site created by Johns Hopkins University Center for Systems Science and Engineering for COVID-19 (JHU/CSSE), which has tracked cases worldwide since the beginning of the pandemic. Our lab developed an in-house RNA test for the virus early.
We had a command center in place with a strategic roll-out of PPE acquisition, creation and distribution. We were one of nine sites that prepared to be a certified treatment site after the Ebola outbreak in 2014 that threated our shores. The plans for the biodome and the scaling of ICU conversions had been in place, and our institution prides itself on a culture of safely, quality and innovation. We are enrolling people on trials, studying biomarkers and trying to make sense of a flood of COVID-19 data using precision medicine and machine learning.
My role in this process has been small. Rick Redett III, MD; C. Scott Hultman, MD, MBA; Jaimie Shores, MD; and Mohammed Alrakan, MD, also volunteered from our department. I admit that when I signed up, I felt some guilt about being called a hero by my non-medical friends as I sat at home doing telemedicine and reading about the front lines. I hoped that by volunteering, I could protect my residents from being volun-told – as they are still in the E.D., sewing up lacerations, seeing consults and putting themselves at risk.
My medical school friends in critical care, emergency medicine and primary care, and my colleagues in New York, are the real heroes. Our nurses, respiratory therapists, technicians and housekeeping staff, who carry on with professionalism and grit, are the quiet warriors in this battle. I'm glad I volunteered. I may not have had profound impact on any one patient's care, but I did my part. At the same time, I learned a great deal about myself, my colleagues and my institution. New connections were formed across specialties that rarely interface. We are cross-trained and can re-engage again if needed. A second wave of COVID-19 seems all but inevitable. These patients will need doctors, and it's important to remember that as plastic surgeons we are physicians first – and capable of caring for the sickest among us.