Autumn in the COVID-19 ICU
In late October, an older man lay on his stomach on a hospital bed. His head was balanced on a pillow, and his eyes were closed. The pillow hung a little off the bed and so part of the man’s head dangled slightly with it, just past the sheets. He faced the windows and a part of his upper back had become bared. The position he was in is called proning and it is used to coax better performance from your lungs.
This was in the COVID-19 Intensive Care Unit of North Shore University Hospital in Manhasset, but the position has become a common practice in Long Island's COVID ICUs.
Earlier this month and a few miles to the south, for example, a woman in her early 30s was proned in the Long Island Jewish Medical Center's COVID ICU. The young woman had recently moved to New York from Eastern Europe, and she had gone into the hospital having trouble breathing. She and her husband didn’t speak English fluently and didn’t understand how she could have contracted coronavirus. They did not know many people in the country. Within hours, the woman was on a ventilator and proned. She stayed that way for around 18 hours and then was flipped.
She "was flipped" because patients don't flip themselves in a COVID ICU. The units are home to ventilated, unconscious patients. So to turn them, the process can take four or five or six people working to make sure intravenous lines and breathing tubes stay connected. Being on a ventilator itself is typically very invasive in severe cases. The device will help you breathe but includes tubes down windpipes. There is also a feeding tube, and patients are sedated, partially to deal with the pain.
Adjustments have to be made to allow patients to lie proned, sedated, for 17 or 18 hours a day. That includes the kinds of padding placed on the woman in LIJ. She had patches on her forehead and on the front of her legs to prevent breakdown of her skin. That's a small price to pay, because proning has become a key COVID-19 therapy, increasing oxygen levels. A study in the American Thoracic Society’s journal suggests that proning can be a "life-saving, proven effective treatment." On Long Island amid the pandemic, it is sometimes explained more starkly. As in this grim statement from a surgical-gowned fellow outside the Eastern European patient’s room: Talking about a patient in the room next to hers, he said, "I’ll prone him until he’s better or dead."
This is the reality of the pandemic on Long Island, some three-quarters of a year into it. If the year of sickness and quarantine were a day, we would just be getting ready to be un-proned. But we are not getting better — or, at least, the pandemic isn’t nearly over — which has put many of Long Island’s hospitals in a strange position. Their staff weathered the spring storm when the region was at the center of the pandemic, which has since mushroomed to more than 12 million infections nationwide and claimed more than 250,000 lives. They saw more death than some doctors and nurses had seen in years. They learned or adopted lessons like proning to improve their treatments and did improve them, significantly. And now they worry about how much more they are going to have to put those treatments to the test.
That's partially because there is a wide — and potentially dangerous — gap between the way things look in the hospitals and in the outside world. It is a gap that is immediately obvious in a COVID ICU — like at North Shore, where critical care specialist Dr. Sean Dhar was finishing his visit to the proned man with his head faced away on the pillow just before a new critically ill COVID-19 patient was wheeled in.
The new patient had been put on a ventilator. His son didn’t quite understand the severity of the situation, another doctor explained to Dhar. The son thought his father would be on the ventilator for just a few days.
That was unlikely. Some patients can spend weeks on the ventilators, and it could take that long for them to get off — or die. Dhar said the new patient was in pretty bad shape. If he doesn't improve soon, Dhar said, we’ll probably have to prone.
Tough decisions by the book
Artwork outside Mount Sinai South Nassau. Credit: Newsday/Mark Chiusano
These are the decisions being made every day in Long Island hospitals, the kind of startling scenes that can feel like another world, as health care workers try to prevent the spring nightmare from coming back in full.
Markers of that nightmare are everywhere, from operating rooms to parking lots. Dylan Brady of Malverne was running the hospital valet parking stand outside Mount Sinai South Nassau at the end of October. The 20-year-old says he touches around 100 cars a day now, but at the height of the pandemic, with no visitors, it was rare to get one.
Sometimes the markers are physical, like for Dr. Susan Donelan of Stony Brook University Hospital, who was serving as the medical consultant for a vaccine distribution exercise in mid-October. Donelan had a marble notebook with her that was one in a series: "This is my ninth COVID book," she said. The well-worn notebooks were her touchstones and scrawlings over months of calls, webinars, interviews, meetings, and terrible data points. Ask her what was going on back in April and — flip the pages — she can tell you: At one point, they had over 430 patients: "That was our height, on April 10."
The height of the pandemic here was unimaginable. That is also something people on the outside still may not understand. Dr. Adey Tsegaye, director of the Medical Intensive Care Unit at LIJ, which served some hard hit parts of Queens as well as Nassau in the spring, calls one particular stretch of days "that horrible week," when she remembers staff opening another ICU almost every day. Because the last one was too full.
Multiple nurses or doctors in conversations in ICUs, hospital corridors or quiet offices spoke about PTSD, having "a little" or "a bit" of it, as if they were exaggerating or almost bashful. But it would not be a surprise to learn that responders struggled with their experiences, from the just-graduated nursing students to seasoned administrators.
"In the beginning, no one was getting better," said Dr. Sameer Khanijo, director of the Respiratory Care Unit at North Shore. "It was depressing."
On a recent morning, Khanijo checked on patients in the regular ICU at North Shore, not the COVID one. He walked into one room with an unresponsive patient, rubbed the man’s chest and introduced himself even though the man couldn’t hear. A staffer cleaning the area walked in and out emptying the garbage, unbothered (there was no door).
It was different in the North Shore COVID ICU. One nurse stood outside the double doors of a patient’s room remembering her first time in a COVID room. Luckily, she had sufficient personal protective equipment, not a given at all hospitals in the region, and she said she had a moment of thinking, "Am I really doing this? Am I going in there?" But then her training kicked in, and she did, and does.
"Poor peanut," she said looking at her patient alone in the room. The patient, an older woman who had at one point improved so much she’d gone home, was small and looked shrunken and now wasn’t doing well. Her room was filled with the sound of bubbling, from a machine to suck out fluid after a lung collapse. Like the others needing extreme ventilator support, she was unconscious. Her hospital gown had shifted a little, showing more of her stomach — one of the nurses smoothed it. But soon the nurses were out and watching from a monitor.
There are no visitors here, unless perhaps someone is "actively dying," said Dhar of North Shore. Seeing a friend or relative proned is striking, upsetting. FaceTime visits are substitutes and sometimes FaceTime numbers are written in Sharpie on patient windows next to doodles of dogs and trees and birds — there are the stories of nurses helping families say goodbye by video call. But again, the critically ill ventilated patients there are sedated and unresponsive.
No small medical miracles
Stars outside Mount Sinai South Nassau. Credit: Newsday/Mark Chiusano
Still, there are spurts of hope. Hospitals are better prepared now, better stocked on supplies, with newly installed doors on patient rooms to prevent spread, and empty space for virus surges. Fewer COVID-19 patients means more time to care for them. With better treatment options and more knowledge about the virus, patients are getting better.
A man being checked on by Tsegaye at LIJ, for example, had been on the ventilator for 15 days. That’s a long time, but Tsegaye's experience this year had taught her to wait and watch. The patient now appeared to be improving, and the amount of air the man was getting via ventilation was now only similar to levels in the room at large. His chest rose and fell.
"Wake up sir," Tsegaye said, leaning close. The man didn’t, but still Tsegaye was smiling and optimistic coming out of the room. "I am so happy."
This is positive thinking in a COVID ICU, where now perhaps the majority of patients will come off their ventilators and no longer be lying on their stomachs being breathed by tubes. These medical miracles would be much less needed if more New Yorkers followed public health guidelines. That is not happening.
"It’s an out-of-sight, out-of-mind perception," says Rachael Piltch-Loeb, a public health emergency expert at the Harvard T.H. Chan School of Public Health. "Everybody needs to be on board in order for this to be effective. And I think that when you cannot see the impact or the virus, the threat, whatever you want to call it, it's really difficult to sustain that level of effort from broad swathes of the community."
Multiple vaccines are in the pipeline, but even the best expected timeline to normality stretches many months into the new year. Some Long Island doctors worry vaccination will not be a straightforward return to normal. First there are all the logistics, for which hospitals like Stony Brook are getting ready. At their October "Point of Dispensing" exercise in the airy Health Sciences Center Galleria, staff gamed out how they’d run 24 hours and maintain refrigerated doses and a one-way flow for people getting inoculated.
Then there’s the question of whether enough people will even get vaccinated, given swirls of misinformation and concern about an unusually sped-up development process.
Anthony Santella, associate professor of public health at Hofstra, said he was recently at a virtual public health conference and a "very well known" public health scholar was asked what she would need to see happen to actually take the COVID-19 vaccine. Santella said that she answered, "I'd want to see every member of Congress get the COVID vaccine, and then spend three days in the hospital with COVID patients, leave, get tested again, and not be sick from COVID."
Enter the nightmares for Long Island health workers, the ones who will be working through the next few months, checking patients and proning them, helping them breathe.
"I think more than anything the holidays are what terrifies me," said Dr. Tsegaye away from the ICU and her hopeful patient, back in her office. On the wall was a flyer asking staff for their COVID stories, for a book being put together about the pandemic experiences of the Critical Care Division. But the story is just at its midpoint.
"The sensation that it’s over — I understand it, but it’s frustrating," she said. Soon she’d be back in the ICU, trying to save people. There are sad and disturbing things you see in COVID units beyond proning. She wanted people to know that children can get sick, too, that’s important to remember. And families should have some plan for what would happen if a family member falls ill, some idea of what they would do.
"It’s a horrible way to die," she said.
Mark Chiusano is a member of the Newsday editorial board.
