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| What Doctors on the Front Lines Wish They’d Known a Month Ago | What Doctors on the Front Lines Wish They’d Known a Month Ago |
| (4 days later) | |
| Just about a month ago, people stricken with the new coronavirus started to arrive in unending ranks at hospitals in the New York metropolitan area, forming the white-hot center of the pandemic in the United States. | Just about a month ago, people stricken with the new coronavirus started to arrive in unending ranks at hospitals in the New York metropolitan area, forming the white-hot center of the pandemic in the United States. |
| Now, doctors in the region have started sharing on medical grapevines what it has been like to re-engineer, on the fly, their health care systems, their practice of medicine, their personal lives. | Now, doctors in the region have started sharing on medical grapevines what it has been like to re-engineer, on the fly, their health care systems, their practice of medicine, their personal lives. |
| Doctors, if you could go back in time, what would you tell yourselves in early March? | Doctors, if you could go back in time, what would you tell yourselves in early March? |
| “What we thought we knew, we don’t know,” said Dr. Nile Cemalovic, an intensive care physician at Lincoln Medical Center in the Bronx. | “What we thought we knew, we don’t know,” said Dr. Nile Cemalovic, an intensive care physician at Lincoln Medical Center in the Bronx. |
| Medicine routinely remakes itself, generation by generation. For the disease that drives this pandemic, certain ironclad emergency medical practices have dissolved almost overnight. | Medicine routinely remakes itself, generation by generation. For the disease that drives this pandemic, certain ironclad emergency medical practices have dissolved almost overnight. |
| The biggest change: Instead of quickly sedating people who had shockingly low levels of oxygen and then putting them on mechanical ventilators, many doctors are now keeping patients conscious, having them roll over in bed, recline in chairs and continue to breathe on their own — with additional oxygen — for as long as possible. | The biggest change: Instead of quickly sedating people who had shockingly low levels of oxygen and then putting them on mechanical ventilators, many doctors are now keeping patients conscious, having them roll over in bed, recline in chairs and continue to breathe on their own — with additional oxygen — for as long as possible. |
| The idea is to get them off their backs and thereby make more lung available. A number of doctors are even trying patients on a special massage mattress designed for pregnant women because it has cutouts that ease the load on the belly and chest. | The idea is to get them off their backs and thereby make more lung available. A number of doctors are even trying patients on a special massage mattress designed for pregnant women because it has cutouts that ease the load on the belly and chest. |
| Other doctors are rejiggering CPAP breathing machines, normally used to help people with sleep apnea, or they have hacked together valves and filters. For some critically ill patients, a ventilator may be the only real hope. | Other doctors are rejiggering CPAP breathing machines, normally used to help people with sleep apnea, or they have hacked together valves and filters. For some critically ill patients, a ventilator may be the only real hope. |
| Then there is the space needed inside of buildings and people’s heads. In an instant, soaring atrium lobbies and cafeterias became hospital wards; rarely-used telemedicine technology has suddenly taken off, and doctors are holding virtual bedside conferences with scattered family members; physicians force themselves to peel away psychically and emotionally from fields of battle where the opponent never observes the cease-fire that the rest of society has entered. | Then there is the space needed inside of buildings and people’s heads. In an instant, soaring atrium lobbies and cafeterias became hospital wards; rarely-used telemedicine technology has suddenly taken off, and doctors are holding virtual bedside conferences with scattered family members; physicians force themselves to peel away psychically and emotionally from fields of battle where the opponent never observes the cease-fire that the rest of society has entered. |
| More than 12,000 people have died with coronavirus in Connecticut, New Jersey and New York, where there are more than 260,000 confirmed cases. Those numbers almost certainly understate the casualties, officials acknowledge, as testing of both the living and the dead remains spotty. | More than 12,000 people have died with coronavirus in Connecticut, New Jersey and New York, where there are more than 260,000 confirmed cases. Those numbers almost certainly understate the casualties, officials acknowledge, as testing of both the living and the dead remains spotty. |
| The New York-area doctors have not uncovered any surefire way to fight Covid-19 — the disease caused by the virus — and not enough time has passed to say if their improvisations will hold up, said Dr. Anand Swaminathan, an assistant clinical professor of emergency medicine at St. Joseph’s University Medical Center in Paterson, N.J. | The New York-area doctors have not uncovered any surefire way to fight Covid-19 — the disease caused by the virus — and not enough time has passed to say if their improvisations will hold up, said Dr. Anand Swaminathan, an assistant clinical professor of emergency medicine at St. Joseph’s University Medical Center in Paterson, N.J. |
| No one knows if any of the spaghetti will stick to the wall. | No one knows if any of the spaghetti will stick to the wall. |
| “I’m confident that we will have a lot of answers in months,” said Dr. Reuben Strayer, an emergency medicine physician at Maimonides Medical Center in Brooklyn. “Unfortunately, that doesn’t help us right now. You have to start somewhere.” | “I’m confident that we will have a lot of answers in months,” said Dr. Reuben Strayer, an emergency medicine physician at Maimonides Medical Center in Brooklyn. “Unfortunately, that doesn’t help us right now. You have to start somewhere.” |
| “Never in my life have I had to ask a patient to get off the telephone because it was time to put in a breathing tube,” said Dr. Richard Levitan, who recently spent 10 days at Bellevue Hospital Center in Manhattan. | “Never in my life have I had to ask a patient to get off the telephone because it was time to put in a breathing tube,” said Dr. Richard Levitan, who recently spent 10 days at Bellevue Hospital Center in Manhattan. |
| Why is this so odd? People who need breathing tubes, which connect to mechanical ventilators that assist or take over respiration, are rarely in any shape to be on the phone because the level of oxygen in their blood has declined precipitously. | Why is this so odd? People who need breathing tubes, which connect to mechanical ventilators that assist or take over respiration, are rarely in any shape to be on the phone because the level of oxygen in their blood has declined precipitously. |
| If conscious, they are often incoherent and are about to be sedated so they do not gag on the tubes. It is a drastic step. | If conscious, they are often incoherent and are about to be sedated so they do not gag on the tubes. It is a drastic step. |
| Yet many Covid-19 patients remain alert, even when their oxygen has sharply fallen, for reasons health care workers can only guess. (Another important signal about how sick the patients are from Covid-19 — the presence of inflammatory markers in the blood — is not available to physicians until laboratory work is done.) | Yet many Covid-19 patients remain alert, even when their oxygen has sharply fallen, for reasons health care workers can only guess. (Another important signal about how sick the patients are from Covid-19 — the presence of inflammatory markers in the blood — is not available to physicians until laboratory work is done.) |
| Some patients, by taking oxygen and rolling onto their sides or on their bellies, have quickly returned to normal levels. The tactic is called proning. | Some patients, by taking oxygen and rolling onto their sides or on their bellies, have quickly returned to normal levels. The tactic is called proning. |
| Doctors at Montefiore Medical Center in the Bronx and Mount Sinai Medical Center in Manhattan have described it on Twitter; a flier is posted next to beds at Elmhurst Hospital Center in Queens as a guide for patients on how often to turn themselves. | Doctors at Montefiore Medical Center in the Bronx and Mount Sinai Medical Center in Manhattan have described it on Twitter; a flier is posted next to beds at Elmhurst Hospital Center in Queens as a guide for patients on how often to turn themselves. |
| At Lincoln Hospital in the Bronx, Dr. Nicholas Caputo followed 50 patients who arrived with low oxygen levels between 69 and 85 percent (95 is normal). After five minutes of proning, they had improved to a mean of 94 percent. Over the next 24 hours, nearly three-quarters were able to avoid intubation; 13 needed ventilators. Proning does not seem to work as well in older patients, a number of doctors said. | At Lincoln Hospital in the Bronx, Dr. Nicholas Caputo followed 50 patients who arrived with low oxygen levels between 69 and 85 percent (95 is normal). After five minutes of proning, they had improved to a mean of 94 percent. Over the next 24 hours, nearly three-quarters were able to avoid intubation; 13 needed ventilators. Proning does not seem to work as well in older patients, a number of doctors said. |
| No one knows yet if this will be a lasting remedy, Dr. Caputo said, but if he could go back to early March, he would advise himself and others: “Don’t jump to intubation.” | No one knows yet if this will be a lasting remedy, Dr. Caputo said, but if he could go back to early March, he would advise himself and others: “Don’t jump to intubation.” |
| The total number of people who are intubated is now increasing by 21 per day, down from about 300 at the end of March. The need for mechanical ventilators, while still urgent, has been less than the medical community anticipated a month ago. | The total number of people who are intubated is now increasing by 21 per day, down from about 300 at the end of March. The need for mechanical ventilators, while still urgent, has been less than the medical community anticipated a month ago. |
| One reason is that contrary to expectations, a number of doctors at New York hospitals believe intubation is helping fewer people with Covid-19 than other respiratory illnesses and that longer stays on the mechanical ventilators lead to other serious complications. The matter is far from settled. | One reason is that contrary to expectations, a number of doctors at New York hospitals believe intubation is helping fewer people with Covid-19 than other respiratory illnesses and that longer stays on the mechanical ventilators lead to other serious complications. The matter is far from settled. |
| “Intubated patients with Covid lung disease are doing very poorly, and while this may be the disease and not the mechanical ventilation, most of us believe that intubation is to be avoided until unequivocally required,” Dr. Strayer said. | “Intubated patients with Covid lung disease are doing very poorly, and while this may be the disease and not the mechanical ventilation, most of us believe that intubation is to be avoided until unequivocally required,” Dr. Strayer said. |
| Updated June 5, 2020 | Updated June 5, 2020 |
| A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study. | |
| The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April. | The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April. |
| Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission. | Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission. |
| Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home. | Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home. |
| States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people. | States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people. |
| Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks. | Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks. |
| Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days. | Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days. |
| If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.) | If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.) |
| Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications. | Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications. |
| The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing. | The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing. |
| If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others. | If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others. |
| If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested. | If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested. |
| This shift has lightened the load on nursing staffs and the rest of the hospital. “You put a tube into somebody,” Dr. Levitan said, “and the amount of work required not to kill that person goes up by a factor of 100,” creating a cascade that slows down laboratory results, X-rays and other care. | This shift has lightened the load on nursing staffs and the rest of the hospital. “You put a tube into somebody,” Dr. Levitan said, “and the amount of work required not to kill that person goes up by a factor of 100,” creating a cascade that slows down laboratory results, X-rays and other care. |
| By committing all the resources of the hospital to highly complex care, mass mechanical ventilation of patients forms a medical Maginot line. | By committing all the resources of the hospital to highly complex care, mass mechanical ventilation of patients forms a medical Maginot line. |
| For heavier patients, Dr. Levitan advocates combining breathing support from a CPAP machine or regular oxygen with comfortable positioning on a pregnancy massage mattress. He had one shipped to the hotel where he was staying in New York and brought it to Bellevue. | For heavier patients, Dr. Levitan advocates combining breathing support from a CPAP machine or regular oxygen with comfortable positioning on a pregnancy massage mattress. He had one shipped to the hotel where he was staying in New York and brought it to Bellevue. |
| The first patient to rest on it arrived with oxygen saturation in the 40s, breathing rapidly and with an abnormally fast heartbeat, he said. After the patient was given oxygen through a nasal cannula — clear plastic tubes that fit into the nostrils — Dr. Levitan helped her to lie face down on the massage table. The oxygen level in her blood climbed to the mid-90s, he said, her pulse slowed to under 100 and she was breathing at a more normal pace. “She slept for two hours,” he said. | The first patient to rest on it arrived with oxygen saturation in the 40s, breathing rapidly and with an abnormally fast heartbeat, he said. After the patient was given oxygen through a nasal cannula — clear plastic tubes that fit into the nostrils — Dr. Levitan helped her to lie face down on the massage table. The oxygen level in her blood climbed to the mid-90s, he said, her pulse slowed to under 100 and she was breathing at a more normal pace. “She slept for two hours,” he said. |
| His brothers are donating more mattresses. | His brothers are donating more mattresses. |
| “We have to see how it pans out, but it makes a lot of sense,” Dr. Swaminathan said. “Obesity is clearly a critical risk factor.” | “We have to see how it pans out, but it makes a lot of sense,” Dr. Swaminathan said. “Obesity is clearly a critical risk factor.” |
| Dr. Josh Farkas, who specializes in pulmonary and critical care medicine at the University of Vermont, said the risks of proning were low. “This is a simple technique which is safe and fairly easy to do,” Dr. Farkas said. “I started doing this some years ago in occasional patients, but never imagined that it would become this widespread and useful.” | Dr. Josh Farkas, who specializes in pulmonary and critical care medicine at the University of Vermont, said the risks of proning were low. “This is a simple technique which is safe and fairly easy to do,” Dr. Farkas said. “I started doing this some years ago in occasional patients, but never imagined that it would become this widespread and useful.” |
| This was rebuilding the engine on a car going 100 miles per hour. | This was rebuilding the engine on a car going 100 miles per hour. |
| “I wouldn’t be surprised if in a couple of weeks someone around the country comes up with better way to do this,” Dr. Swaminathan said. | “I wouldn’t be surprised if in a couple of weeks someone around the country comes up with better way to do this,” Dr. Swaminathan said. |
| The medical community is in desperate need of research but there is no time to wait. “Everyone’s got an observation,” Dr. Strayer said. “Everyone’s got an opinion. It’s not very useful. What matters is science and we don’t have any yet.” | The medical community is in desperate need of research but there is no time to wait. “Everyone’s got an observation,” Dr. Strayer said. “Everyone’s got an opinion. It’s not very useful. What matters is science and we don’t have any yet.” |
| After shifts filled entirely with the stress of uncertainty, doctors use their own maps to hunt down peace at day’s end. | After shifts filled entirely with the stress of uncertainty, doctors use their own maps to hunt down peace at day’s end. |
| “I live alone,” said Dr. Strayer. “That turns out to be a huge advantage for me and my own well-being.” | “I live alone,” said Dr. Strayer. “That turns out to be a huge advantage for me and my own well-being.” |
| Dr. Swaminathan said he goes through a decontamination ritual before driving home to his wife and children. “We decided moving out was not an option,” he said. They keep him sane. He has Zoom sessions with friends who work outside of medicine. And there were surprises. | Dr. Swaminathan said he goes through a decontamination ritual before driving home to his wife and children. “We decided moving out was not an option,” he said. They keep him sane. He has Zoom sessions with friends who work outside of medicine. And there were surprises. |
| “Someone tweeted the English National Ballet musicians, doing a Zoom session playing Tchaikovsky’s ‘Swan Lake,’” he said. “I listened to it. I noticed my whole body relaxed.” | “Someone tweeted the English National Ballet musicians, doing a Zoom session playing Tchaikovsky’s ‘Swan Lake,’” he said. “I listened to it. I noticed my whole body relaxed.” |